ill 


€t)e  Librarp 

of  the 

Glntoeusitp  of  Jftortb  Carolina 


(EnDotoeo  bp  TOc  Dialectic 

anH 

P&ilant&ropic  feocic tire 


£17.3*3 


a  *- .  /<P6X . 


V 


w 


1   \       N- 


^    C«V\v 


Digitized  by  the  Internet  Archive 

in  2011  with  funding  from 

University  of  North  Carolina  at  Chapel  Hill 


http://www.archive.org/details/manualofmilitarychis 


MANUAL 


MILITARY  SURGERY, 


FOR   THE    USE    OF 


SURGEONS  IN  THE  CONFEDERATE  ARMY; 


WITH  AN  APPENDIX  OF  THE 


Stoles  and  Initiations  of  the  JRedfcal  geprtment 


CONFEDERATE     ARMY. 

BY 

J.  JULIAN  CHISOLM,  M.  D., 

PROFESSOR    OF    SURGERY  IN    THE    MEDICAL    COLLEGE    OF    THE    STATE    OF 
SOUTH    CAROLINA,  ETC. 


RICHMOND,   VA. 
WEST    &    JOHNSTON, 

145  Main  Street. 

1861. 


Entered  according  to  Act  of  Congress,  in  the  year  1861.  by 

J.  J.  CHISOLM,  M.  D., 

In  the  Clerk's  Office  of  the  District  Court  of  the  Confederate  States  for  the 
District  of  Charleston,  South  Carolina. 


Evans  &  Cogswell.  Printers.  Xo.  3  Broad  street.  Charleston.  S.  C. 


PREFACE. 


In  putting  forth  this  Manual  of  Military  Surgery  for  the  use 
of  surgeons  in  the  Confederate  service,  I  have  been  led  by  the 
desire  to  mitigate,  if  possible,  the  horrors  of  war  as  seen  in  its 
most  frightful  phase  in  military  hospitals.     As  our  entire  army 
is  made  up  of  volunteers  from  every  walk  of  life,  so  we  find  the 
surgical  staff  of  the  army  composed  of  physicians  without  surgi- 
cal experience.     Most  of  those  who  now  compose  the  surgical 
staff  were  general  practitioners,  whose  country  circuit  gave  them 
but  little  surgery,  and  very  seldom  presented  a  gunshot  wound. 
Moreover,  as  our  country  had  been  enjoying  an  uninterrupted 
state  of  peace,  the  collecting  of  large  bodies  of  men,  and  retain- 
ing them  in  health,  or  the  hygiene  of  armies  had  been  a  study 
without  an  object,  and  therefore  without  interest.     When  the 
war  suddenly  broke  upon  us,  followed  immediately  by  the  block- 
ading of  our  ports,  all  communication  was  cut  off  with  Europe, 
which  was  the  expected  source  of  our  surgical  information.     As 
there  had   been   no   previous   demand   for   works   on   military 
surgery,  there  were  none  to  be  had  in  the  stores,  and  our  physi- 
,.    cians   were   compelled   to   follow   the    army   to   battle   without 
flO  instruction.     No  work  on  military  surgery  could  be  purchased 
I^in  the  Confederate  States.     As  military  surgery,  which  is  one  of 
%,  expediency,  differs  so  much  from   civil   practice,  the  want  of 
^proper  information  has  already  made  itself  seriously  felt.     In 


KZ  M 


IV  PREFACE. 

times  of  war,  where  invasion  threatens,  every  citizen  is  ex- 
pected to  do  his  duty  to  his  state.  I  saw  no  better  means  of 
showing  my  willingness  to  enlist  in  the  cause  than  by  preparing 
a  manual  of  instruction  for  the  use  of  the  army,  which  might 
be  the  means  of  saving  the  lives  and  preventing  the  mutilation 
of  many  friends  and  countrymen.  The  present  volume  con- 
tains the  fruit  of  European  experience,  as  dearly  purchased  in 
recent  campaigning.  Besides  embodying  the  experience  of  the 
masters  in  military  surgery  as  to  the  treatment  of  wounds,  I 
have  incorporated  chapters  upon  the  food,  clothing  and  hygiene 
of  troops;  with  directions  how  the  health  of  an  army  is  to  be 
preserved,  and  how  an  effective  strength  is  to  be  sustained; 
also,  the  duties  of  military  surgeons,  both  in  the  camp  and  in 
the  field.  In  an  appendix  will  be  found  the  regulations  and 
forms  for  the  use  of  the  Medical  Department  of  the  Confederate 
army.  In  preparing  this  volume,  I  have  not  hesitated  to  add 
to  my  own  experience  in  the  treatment  of  surgical  injuries,  any 
useful  information  which  I  could  obtain  from  the  most  recent 
German,  French  and  English  works,  on  military  surgery;  and 
in  many  instances,  where  the  language  used  by  them  expressed 
to  the  point  the  subject  under  discussion,  I  have  not  hesitated  to 
transfer  entire  sentences  directly  to  these  pages.  I  make  this 
acknowledgment,  en  masse,  of  the  very  liberal  use  of  the  fol- 
lowing works,  as  quotation  marks  were  sometimes  overlooked : 

Maximen  der  Kriegsheilkunst,  von  L.  Stromeyer,  Hanover, 
1855;  supplement  der  Maximen  der  Kriegsheilkunst,  von  L. 
Stromeyer,  Hanover,  1860  ;  Loeffler  Behandlung  der  Schuss- 
wunde,  Berlin,  1859;  Histoire  Medico-Chirurgicale  de  la  Guerre 
de  Crimee,  par  le  docteur  Adolphe  Armand,  Paris,  1858;  La 
Guerre  de  Crimee,  par  L.  Baudens,  Paris,  1858;  Des  Plaies " 
d'Armes  a  feu;  Communications — Faites  a  1' Academic  Nationale 
de  Medeeine,  Paris,   1849  ;  Notes  of  the    Wounded,  from  the 


PREFACE.  V 

Mutiny  in  India,  by  George  Williamson,  London,  1859  ;  Coles' 
Military  Surgery,  with  Experience  of  Field  Practice  in  India, 
London,  1852 ;  Gunshot  Wounds  of  the  Chest,  by  Patrick 
Fraser,  M.  D.,  London,  1859  ;  Guthrie's  Commentaries  on  Mili- 
tary Surgery,  London,  1855;  McLeod's  Notes  on  the  Surgery 
of  the  Crimean  War,  London,  1858  ;  Hennen's  Principles  of 
Military  Surgery ;  Larrey's  Military  Surgery ;  Ballingall's  Out- 
lines of  Military  Surgery  ;  Gross'  System  of  Surgery ;  Erich- 
sen's  Science  and  Art  of  Surgery ;  Jackson  on  the  Formation, 
Discipline,  and  Economy  of  Armies. 


INDEX. 


Abdominal  wounds 301 

Ambulance  carriages  for  the  wounded S6 

Amputations,  rules  for 374 

Amputation  of  arm,  when  required 324 

Amputation  of  lower  extremity,  when  required 369 

Amusements  in  camp 59 

Anaesthetics 379 

Arm,  injuries  to 320 

Arteries,  wounds  of. 152 

Assistant  surgeon,  duties  of 106 

Balls,  different  wounds  by 135 

Beds  for  soldiers 55 

Beds  for  hospitals 64 

Boots  for  soldiers 32 

Camps - 53 

Camp  duties  of  surgeon 100 

Carriers  for  the  wounded 92 

Chest  wounds 276 

Chloroform 379 

Circular  amputations  to  be  preferred 374 

Clothing  of  troops 26 

Clothing,  physiology  of 27 

Clothing,  allowance  of  by  the  Confederate  Service 37 

Cleanliness,  importance  of 40 

Cleanliness  of  camp   57 

Cleanliness,  when  excessive,  injurious  to  wounds 337 

Compression  in  head  injuries 245 

Concussion  in  head  injuries 238 

Cold  water  only  dressing  for  wounds 164 

Color  of  uniform 35 

Coffee,  utility  of  in  an  army 42 

Confederate  medical  service 99 


Compound  fracture  of  arm 323 

Compound  fracture  of  leg 359 

Depression  of  skull 257 

Diarrhoea 11 

Diet  in  hospitals 77 

Division  of  labor  in  fiell  infirmaries 115 

Diseases  vs.  wounds 21 

Diseases  of  Maryland 4 

Diseases  which  an  army  will  encounter  in  the  Middle  States 10 

Dressings  carried  by  each  soldier 97 

Dressings  required  in  the  battle  field 110 

Dressing  of  wounds 130 

Dressing  of  stumps 376 

Duties  of  a  surgeon  in  camp 100 

Duties  of  a  surgeon  on  the  battle  field 109 

Dysentery 12 

Endermic  use  of  morphine 188 

Enlistments 13 

English  medical  service 89 

Erysipelas 192 

Erysipelas  common  to  middle  States 8 

Examination  of  wounds 124 

Extraction  of  foreign  bodies 148 

Face  wounds 268 

Female  nurses  in  military  hospitals 75 

Field  surgery 119 

Foreign   bodies  in  wound 145 

Fracture  of  the  skull 250 

Fracture  of  the  jaw 269 

Fracture  of  the  ribs 299 

Fracture  of  the  upper  extremity 32fi 

Fracture  of  the  lower  extremity 389 

Pood 41 

French  medical  service 90 

Gaiter,  in  universal  use  in  the  French  army 33 

Gangrene 210 

General  hospital ' 67 

Gunshot  wounds 133 

Hat,  military 35 

Head  injuries '. 237 

Hectic 233 

Hemorrhage,  primary 152 

Hemorrhage,  secondary i 169 


INDEX.  IX 

Hemorrhage,  abdominal 314 

Hip-joint  injuries 353 

History  of  wounds  necessary  for  diagnosis 147 

Horse  litters  for  the  wounded 85 

Hospital  tent 63 

Hospital  attendants 65 

Hospital  gangrene 210 

Inflammation  of  bone 267 

Illinois,  medical  topography  of 8 

Inferior  extremities,  injuries  of 352 

Intestinal  wounds 306 

Injuries  of  skull 247 

Internal  treatment  of  wounds 183 

Injuries  of  superior  extremity 320 

Joints,  injuries  of  superior  extremity 340 

Joints,  injuries  of  lower  extremity 352 

Kentucky  medical  and  physical  topography 7 

Knee-joint  injury 364 

Leg,  compound  fracture  of 367 

Ligating  arteries 154 

Litters 82 

Lower  jaw,  fractures  of 270 

Lower  extremity,  injuries  of 352 

Lung  wound 282 

Maryland,  topography  of 1 

Material  of  armies 16 

Malarial  fevers 10 

March,  precautions  during 49 

Medical  service  of  the  army 87 

Medical  department  of  the  English  service S9 

Medical  department  of  the  French  service 90 

Medical  department  of  the  Prussian  service . .    . .  91-94 

Medical  department  of  the  Confederate  service 88 

Mess 47 

Morphine  endermically 188 

Mortality  of  our  troops  in  Mexico 20 

Mortification  attacking  a  limb 372 

Neck  wounds 273 

Nervous  shock 127 

Night  air 207 

Nurses  in  hospital 75 

Orifices  of  entrance  and  exit 134 

Opium  in  gunshot  wounds 187 


X  INDEX. 

Ostitis 267 

Overcoat  for  soldiers 34 

Over-care  of  wounds 337 

Perforating  wounds  of  skull 265 

Perforating  wounds  of  chest 2S0 

Primary  hemorrhage 152 

Probing  of  wounds 123 

Preparations  for  a  battle  by  the  surgeon 100 

Primary  dressing  carried  by  each  soldier 97 

Privies  in  camp 57 

Precautions  before  a  march 49 

Prussian  medical  service 91 

Prussian  medical  service  on  battle  field 94 

Purification  of  hospitals 69 

Pyseniia 201 

Rations  in  the  Confederate  service 45 

Recruits 19 

Resections 343 

Removal  of  foreign  bodies 148 

Ribs,  fracture  of 299 

Rules  for  amputation 369 

Sanitary  corps  of  carriers 92 

Scalp  wounds 249 

Shoes 32 

Shirts 31 

Secondary  hemorrhage 169 

Sequel*  of  gunshot  wounds 232 

Severely  wounded  to  be  left  with  the  enemy 132 

Skull  injuries 247 

Spent  ball 218 

Stumps,  dressing  of 376 

Surgeon,  duties  of 100 

Surgical  preparation  for  battle 110 

Straw  for  beds 65 

Statistics  of  killed  in  Mexico 21 

Tennessee  physical  and  medical  topography 7 

Tents  a  labri 53 

Tents  for  hospitals 63 

Tetanus 221 

Thigh,  compound  fracture  of ■: *  •  •  •   359 

Thirst,  how  relieved 50 

Transportation  for  the  wounded 81 

Transportation  to  the  general  hospital 129 


INDEX.  XI 

Trephining ...  25G 

Treatment  at  the  field  infirmary 122 

Treatment  of  gunshot  wounds 127 

Typhus  fever 15 

Typhus  cases  to  be  isolated 73 

Typhoid  fever 8 

Virginia  topography j 

Vegetables  necessary  for  the  soldier -13 

Volunteers 16 

Water,  taken  with  caution  whilst  on  a  march 49 

Water  dressing 162 

Wounds,  gunshot 132 

Wounds,  local  treatment  of 161 

Wounds,  general  treatment  of •. 1 83 

Wounds  of  head 237 

Wounds  of  face 268 

Wounds  of  neck 273 

Wounds  of  chest 270 

Wounds  of  abdomen 301 

Wounds,  early  treatment  of 119 


CHAPTER    I. 

The  Physipal  and  Medical  Topography  of  the  Frontier 
States — Maryland,  Virginia,  Kentucky,  Tennessee, 
Illinois  and  Missouri — their  Geology,  Climate,  and 
Diseases;  at  what  seasons  'prevalent,  and  how  treated 
by  the  local  physicians. 

The  war  which  is  now  being  carried  on  between 
the  United  States  and  Confederate  States  has  lo- 
cated itself,  as  it  were  by  mutual  consent,  upon  the 
frontier,  which  threatens  to  be  the  scene  of  most 
of  the  battles  between  the  contending  armies.  As 
the  middle  region  of  what  was  formerly  called  the 
United  States  will  witness  the  brunt  of  these  con- 
tests, a  brief  description  of  the  country,  with  a 
history  of  the  diseases  most  prevalent  at  different 
seasons  of  the  year,  cannot  but  interest  those  who 
will  have  the  sanitary  condition  of  our  troops 
under  care;  as  it  may  assist  army  surgeons  in 
adopting  a  system  of  hygiene  and  prophylactics 
which  will  be  useful  in  keeping  off  diseases. 

Maryland,  the  first  of  these  border  States  upon 
the  Atlantic  coast,  is  naturally  divided  into  two 

1 


'1  MARYLAND: 

distinct  physical  regions  :  the  one,  an  elevated 
region,  traversed  hy  various  ridges  of  the  Allegha- 
nies,  the  other,  a  flat  country,  scarcely  rising  above 
the  level  of  the  sea,  which  in  turn  is  cleft  un- 
equally by  the  Chesapeake  bay.  The  lowlands  on 
either  side  of  the  bay  are  more  or  less  sandy,  and 
are  freely  indented  by  estuaries  and  checkered 
by  water  courses.  That  portion  of  the  State  bor- 
dering on  the  Chesapeake  is  formed  of  lowlands 
and  meadows.  On  the  margin  of  these  are  salt 
marshes  of  considerable  extent.  Many  of  these 
are  inundated  by  high  tides,  especially  after  the 
prevalence  of  south  winds,  which  force  the  waters 
of  the  Chesapeake  and  its  branches  toward  its 
sources.  As  the  tides  recede,  many  pools  are  left, 
which  in  hot  weather  form  stagnant  foci  of  in- 
fection. The  lowlands  are  covered  with  a  rank 
growth,  the  decomposition  of  which  during  the 
summer  and  autumn  months  charges  the  atmos- 
phere with  offensive  and  deleterious  effluvia. 
Along  these  water  courses  and  in  the  neighbor- 
hood of  such  lowlands,  malaria  abounds,  and  in- 
termittent and  remittent  fevers  are  endemic. 

The  climate,  as  in  all  Southern  latitudes,  is  very 
variable  upon  the  coast,  and  the  excessive  moisture 
in  an  exhilarating  atmosphere,  when  connected 
with  the  heats  of  summer,  predispose  to  affections 


RSt 


ITS   TOPOGRAPHY.  o 

of  the  mucous  membranes.  The  warm  weather 
induces  engorgements  of  the  portal  and  hepatic 
circulation,  with  consecment  derangement  and  in- 
terruption of  the  biliary  secretion,  with  congestion 
and  irritability  of  the  intestinal  mucous  membrane. 
The  sudden  changes  of  temperature,  making  a  rise 
or  fall  of  several  degrees  of  the  thermometer,  often 
in  a  few  minutes,  when  taken  in  connection  with 
suppression  of  perspiration,  will  explain  the  fre- 
quency of  gastric  disturbances,  with  diarrhoea  and 
dysentery.  These  form  the  common  diseases  of 
the  country  during  the  summer  months,  and  im- 
press., to  a  greater  or  less  extent,  all  morbid  condi- 
tions. 

As  the  land  recedes  at  some  distance  from  the 
bay,  it  becomes  uneven.  It  gradually  rolls  into 
upheaved  hills,  the  highest  of  which  are  not  over 
one  hundred  feet  in  height.  As  the  western  por- 
tions of  the  State  are  approached,  the  land  be- 
comes very  hilly  and  rough.  The  high  ridges, 
which  attain  an  elevation  of  2,000  feet  above  the 
level  of  the  sea,  intercept  valleys  remarkable  for  ■ 
the  exuberant  richness  of  the  soil,  which  lies  upon 
a  substratum  of  limestone.  This  is  the  mining 
portion  of  the  State,  which  yields  coal  in  great 
abundance,  and  also  iron.  The  water  of  this 
region  is  very  free  from  impurities,  whether  ob- 


MARYLAND : 


tainted  from  the  numerous  streams,  wells,  or 
springs.  Mineral  waters  are  found  in  several 
localities,  to  many  of  which  invalids  resort  with 
benefit.  During  the  summer  months,  the  hierli- 
lands  of  the  State  are  very  healthy ;  and,  except 
upon  the  low  margins  of  the  water  courses,  where 
the  mild  forms  of  malarial  fevers  are  met  with,  no 
diseases  can  be  called  local.  During  the  winter 
months,  catarrhal  affections  and  pneumonia  are 
the  diseases  of  the  low  countries,  whilst  typhoid 
fever  often  rages  as  an  epidemic  in  the  highest 
regions  of  the  State. 

Malarial  fevers  of  this  region  commence  their 
incursions  about  the  middle  of  July,  and  continue 
three  or  four  months.  They  take  on  either  remit- 
tent or  intermittent  forms,  and  are  of  every  grade 
of  intensity,  from  the  fevers  of  a  day  to  those  fatal 
after  three  or  four  paroxysms.  Intermission  or 
remission  is  their  never-failing  characteristic,  by 
which  they  can  always  be  recognized,  and  their 
lurking  influence  over  other  diseases  detected.  In 
later  years  these  fevers  have  assumed  a  more  man- 
ageable type,  and  yield  readily  to  quinine  when 
given  early  and  in  sufficient  quantity. 

Dj/scntery  occurs  annually  in  both  the  high  and 
low  portions  of  the  country,  and  in  some  seasons 
assumes  the  epidemic  character.     When  this  dis- 


ITS    TOPOGRAPHY.  O 

ease  appears  during  the  autumn  months,  its  asso- 
ciation with  malarious  influences  can  be  discerned, 
and  the  treatment,  which  is  tedious,  must  be  modi- 
fied more  or  less  on  account  of  this  combination. 
When  the  fever  which  accompanies  this  intestinal 
disease  shows  a  periodic  tendency  more  or  less 
marked,  the  curative  power  of  quinine  in  its  treat- 
ment is  proved  to  be  of  decided  utility. 

Catarrhal  fevers  often  ^prevail  extensively  over 
large  districts  of  country,  owing,  perhaps,  to  the 
presence  of  some  subtle  poison  in  the  air  which 
has  eluded  scientific  inquiry.  When  prevalent,  it 
brings  under  its  influence  almost  every  person  in 
those  districts  where  it  makes  its  appearance.  The 
course  of  the  disease  is  to  recovery  after  torment- 
ing its  victims  from  one  to  six  weeks,  and  then 
leaving  them  much  enfeebled.  The  mild  expecto- 
rant plan  of  treatment  is  the  course  generally  pur- 
sued by  the  local  physicians,  except  where  perio- 
dicity shows  itself,  when  a  few  doses  of  the  potent 
medicine,  quinine,  may,  as  if  by  magic,  restore  the 
patient  to  health. 

Virginia  similates,  closely,  Maryland  as  to  its 
topograph}-.  The  coast  line,  running  inward  for 
one  hundred  to  one  hundred  and  twenty  miles,  is 
low  and  sandy,  similarly  indented  with  estuaries, 


b  VIRGINIA  : 

into  which  the  numerous  rivers  of  the  State  empty. 
The  lagoons  are  lined  by  low,  marshy  swamps,  in 
which,  during  the  summer  months,  malaria  is 
generated.  As  we  leave  this  helt,  advancing  west- 
ward, the  country  is  found  undulating,  with  rolling 
lands.  The  soil  is  somewhat  sandy,  but  on  the 
margins  of  the  rivers  are  extensive  alluvions  of 
great  fertility,  producing  fine  crops  of  grain  and 
tobacco,  and  supporting*a  healthy,  sturdy  popula- 
tion. The  climate  is  salubrious,  although  variable. 
Traversing  the  centre  of  the  State  from  north-east 
to  south-west  is  the  Blue  Ridge  and  Alleghany 
chain  of  high  mountains,  rich  in  mineral  produc- 
tions, and  enclosing  fertile  valleys,  which  will  vie 
with  any  lands  on  the  continent  in  productiveness. 
These  valleys  are  filled  with  medicinal  springs  of 
great  virtue.  Many  are  of  world-wide  reputation, 
and  are  annually  resorted  to  by  thousands  for 
health  and  pleasure.  Among  them  are  found  lime, 
soda,  sulphur,  magnesia,  alum,  and  chalybeate 
waters;  also,  hot,  warm  and  cold  springs.  As  the 
beautiful  scenery,  the  bracing  air,  and  excellent 
accommodations  have  their  sanitary  influence, 
especially  when  assisted  by  the  medicinal  waters 
which  abound  eveiywhere  through  these  mountain 
ranges,  the  sick  and  halt  from  the  most  distant 
portions  of  the  country  are  assembled  here  during 


ITS    TOPOGRAPHY. 


the  summer  months.  Nor  are  they  often  disap- 
pointed in  the  cures  which  they  seek.  Change  of 
life  and  scene  is  a  most  potent  remedy  for  good 
to  those  whose  multifarious  duties  at  home  are 
constantly  at  war  with  all  the  laws  of  health. 

"Western  Virginia,  like  the  eastern  portion  of  the 
State  of  Kentucky,  with  which  it  joins,  is  a  broken 
country,  abounding  in  the  finest  limestone  water. 
The  soil  is  fertile,  based  upon  a  substratum  of  blue 
limestone,  which  forms  the  basis  of  this  entire 
region.  In  some  portions,  the  soil  is  a  rich  black 
loam,  and  very  productive  ;  in  other  portions, 
there  is  a  red,  yellowish  or  whitish  clay,  not  so  well 
adapted  for  grain  crops.  When  a  substratum  of 
clay  is  covered  with  a  layer  of  vegetable  mould,  it 
constitutes' a  soil  of  unrivalled  fertility,  in  which 
the  blue  grass  [p>oa  pratensis)  grows  in  the  greatest 
perfection.  A  strong  similarity  exists  between 
the  diseases  of  this  section,  including  Kentucky 
and  those  of  the  eastern  portion  of  the  State.  Ma- 
larial fevers  are  of  a  mild  type,  and  are  found 
very  amenable  to  treatment.  It  is  chiefly  where 
from  freshets  the  rivers  overflow  their  banks,  leav- 
ing deposits  to  be  acted  upon  by  the  hot  sun  of 
summer,  that  malaria  is  generated.  In  many 
low  portions  of  Tennessee  and  Kentucky,  in  the 
neighborhood  of  the  low  banks  of  the  rivers,  the 


S  TENNESSEE    AND    KENTUCKY. 

sources  of  malaria   arc  found  producing  virulent 
cases  of  fever. 

The  western  portions  of  Tennessee  and  Ken- 
tucky, with  the  southern  part  of  Illinois,  are  low 
river  bottoms  of  rich  soil,  covered  with  rank  vegeta- 
tion. This  portion  of  Illinois,  skirting  the  Missis- 
sippi river  for  sixty  miles  in  length  and  seven  in 
width,  is  known  as  "the  great  American  bottom/' 
The  immediate  banks  of  the  river,  from  one-half  to 
one  mile  in  depth,  are  bordered  by  a  heavy  forest, 
behind  which  margin  is  a  rich  prairie  country,  cov- 
ered with  luxuriant  crops  of  grass.  This  prairie 
is  dotted  with  numerous  lakes,  and  as  the  evap- 
oration of  the  water  during  the  latter  part  of 
summer  exposes  the  surface  of  the  subjacent  soil, 
a  fruitful  source  of  disease  is  engendered.  The 
influence  of  this  poisoned  atmosphere  is  so  sensi- 
bly felt  on  the  opposite  side  of  the  river,  which  is 
here  one  mile  wide,  that  at  Jefferson  barracks — a 
beautifully  located  station  in  a  rolling,  thoroughly 
drained  country,  gradually  rising  into  hills  at  an 
elevation  of  two  hundred  feet,  and  one  mile  dis- 
tance from  the  river  bank — nearly  all  the  garrison 
are  affected  by  malarial  fevers  during  the  fall 
months.  The  medical  statistics  of  the  United 
States  army  give,  as  the  annual  average  sickness 


DISEASES    OP    THIS    REGION.  9 

for  twenty-one  years  at  this  post,  eight  hundred 
and  eighty-four  cases  of  malarial  fevers  per  thou- 
sand men.  These  statistics  are  gathered  from  a 
mean  strength  of  nine  thousand  six  hundred  and 
eighty-one  men. 

At  this  station,  intestinal  diseases  are  very  prev- 
alent during  warm  weather.  The  proportion  of 
these,  exclusive  of  Cholera  Asiatica,  amounting  to 
eight  hundred  and  nine  per  thousand.  Asiatic 
Cholera  has  raged  at  this  post  as  an  epidemic  for 
several  consecutive  summers,  having  appeared  in 
1849,  '50,  '51,  '52,  '54  and, '55. 

Among  the  common  diseases  of  this  entire 
range  of  country,  extending  through  all  the  mid- 
dle States  from  the  seahoard  to  the  Mississippi,  can 
now  be  classed  Erysipelas.  For  the  past  ten  or 
twelve  years  it  has  been  found  very  prevalent, 
especially  during  the  winter  months,  when  the 
disease  appears  more  severe.  This,  with  Typhoid 
Fever,  which,  as  a  disease  of  the  winter  season, 
is  also  common  to  this  entire  belt  of  country, 
is  of  comparatively  recent  introduction.  The 
former  inflammatory  character  of  diseases  has 
given  place  to  lower  types,  with  increased  irrita- 
bility of  the  system,  with  its  accompanying  intol- 
erance of  antiphlogistic  treatment  and  urgent  de- 
mands for  protection  and  stimulation. 


10  DISEASES    OF    THIS    REGION. 

The  diseases  which  an  army  must  encounter  (luring 
the  summer  months,  when  encamped  on  the  soil 
of  Maryland,  Virginia,  Kentucky  or  Missouri, 
will  depend  altogether  upon  its  location,  whether 
on  the  low  or  high  lands.  If  in  the  low  country, 
in  the  vicinity  of  water  courses,  malarial  fevers 
may  be  the  most  numerous,  their  frequency  de- 
pending upon  the  degree  of  exposure.  These 
are  found  to  be  amenable  to  treatment,  and  qui- 
nine is  the  great  specific  for  this  common  disease. 
The  majority  of  uncomplicated  cases  will,  accord- 
ing to  the  experience  of  local  physicians,  yield  to 
a  single  dose  of  ten  to  fifteen  grains,  given  ten 
hours  before  the  expected  paroxysm.  To  those  who 
are  especially  exposed  in  scouting  parties  or  in, 
the  swamps,  the  prophylactic  influence  of  quinine 
should  be  extensively  relied  upon,  and  cannot  be 
too  strongly  urged.  Five  grains,  taken  daily,  has 
proved  sufficient  protection  on  the  river  swamps 
of  South  Carolina,  where  malaria  in  its  most  con- 
centrated and  virulent  forms  infests  the  atmos- 
phere. 

When  we  leave  the  coast  line  and  reach  the 
hill}'  countiy,  we  come  to  a  genial  climate  and 
salubrious  country,  where  general  health  can  be 
preserved.  No  malarial  influences  are  here  felt 
except  upon  the  alluvial  banks  of  the  rivers,  where 


DISEASES    OF    THIS    REGION.  11 

it  is  sometimes  met  with  in  a  mild  form  during 
the  autumn  months.  Here  Diarrhoea  and  Dysen- 
tery will  be  the  prevailing  affections,  with  gastric 
disturbances,  and  perhaps  cholera  morbus.  These 
intestinal  diseases  often  rage  epidemicall}7  over  ex- 
tensive tracts,  as  found  in  Reports  to  the  American 
Medical  Association.  All  of  the  Middle  States  are 
common  ground  for  these  general  diseases,  which 
commence  in  June  and  continue  until  October, 
increasing  in  severity  with  the  advance  of  hot 
weather.  Even  among  the  mountain  ranges,  with 
the  most  salubrious  climate,  diarrhoea  shows  itself 
the  prevailing  disease.  From  the  medical  reports 
of  Carlisle  barracks  and  Alleghany  arsenal,  ex- 
tending over  a  series  of  years,  and  which  have 
been  compiled  by  order  of  surgeon-general  Law- 
son,  we  find  the  proportion  of  Diarrhoea  in  the 
garrison  to  number,  annually,  five  hundred  and 
sixty-two  per  thousand,  and  Intestinal  affections, 
exclusive  of  Asiatic  Cholera,  to  be  one  thousand 
and  seven  cases  per  thousand  men. 

Exposure  to  atmospheric  vicissitudes,  eating 
crude  and  indigestible  articles  of  food,  unripe 
fruits  and  vegetables,  intemperance  in  eating  and 
drinking,  irregularity  in  eating,  improper  clothing, 
with  sudden  check  of  perspiration,  are  the  com- 
mon productive  causes  of  intestinal  disturbances. 


12  DISEASES    OF    THIS    REGION. 

These  diseases  show  no  peculiarity;  they  are 
rarely  purely  inflammatory,  and  seldom  demand 
the  strictly  antiphlogistic  plan  of  treatment.  Opi- 
um forms  the  basis  of  treatment  for  most  bowel 
complaints,  in  combination  with  a  little  calomel 
to  excite  secretions  from  the  liver,  and  also  ipecac 
in  small  doses  to  restore  cutaneous  action,  and 
perhaps  camphor,  for  its  general  stimulating- 
effect.  By  the  judicious  use  of  these  remedies, 
intestinal  fluxes  are  readily  controlled. 

When,  from  the  enervating  effects  of  long-con- 
tinued heat,  with  its  sedative  influence  upon  the 
skin,  these  diseases  assume  a  chronic  form,  a  fur- 
lough for  two  or  three  weeks,  with  change  of  air, 
when  assisted  with  mild  astringent  tonics,  will 
be  found  the  most  successful  treatment.  The 
modern  treatment  of  Dysentery  by  salines  and 
opiates  has  called  for  many  advocates,  who  use 
largely  salts  and  laudanum  as  a  prescription  for 
it ;  the  object  being  to  relieve  the  engorgement 
of  the  vessels  with  the  saline  laxative,  whilst  the 
opiate  allays  irritability  and  checks  tormina  and 
tenesmus.  Judging  from  an  analysis  of  the  reports 
handed  in  from  the  various  Middle  States  to  the 
American  Medical  Association,  there  is  no  very 
great  difference  in  the  success  of  these  two  modes 
of  treatment.     External  stimulation  by  dry  heat; 


DISEASES    OF    THIS    REGION. 


cataplasms  of  mustard  or  cayenne  pepper;  frictions, 
in  connection  with  internal  stimulation  by  admin- 
istering the  aethers,  Hofmann's  anodyne,  spirits 
of  camphor,  essence  of  peppermint,  ginger  or 
tincture  of  capsicum,  become  very  necessary  when 
exhaustion  of  the  nervous  powers  and  .collapse, 
with  cold  extremities,  make  their  appearance. 

In  western  Tennessee  and  Kentucky  during  the 
summer  months  malarial  fevers  are  found,  assum- 
ing a  bilious  remittent  or  intermittent  type.  They 
are  amenable  to  the  judicious  administration  of 
the  preparations  of  bark,  of  which  quinine  and 
cinchona  are  the  most  active.  * 

During  the  winter  months,  the  high  region  of 
these  Middle  States  becomes  the  most  unhealthy. 
Catarrhal  affections  prevail  upon  the  coast,  now 
and  then,  taking  on  pneumonic  symptoms;  but 
with  these,  when  not  neglected  in  the  commence- 
ment, there  is  no  fatal  tendency.  In  the  mountain 
lands,  Typhoid  Fever  may  be  expected,  sometimes 
raging  extensively  and  fatally.  It  is  often  the 
leading  disease  of  the  season.  It  generally  runs 
a  uniform  course,  ending  when  skilfully  treated, 
in  convalescence  in  from  fourteen  to  twenty-one 
daj-s.  In  its  treatment,  the  intractable  and  de- 
pressing nature  of  the  disease  must  be  kept  con- 
tinually in  view;  the  aim  of  the  physician   being 


14  DISEASES    OF    THIS    REGION. 

» 

rather  to  brace  up  the  system  against  the  exhaust- 
ing effects  of*  the  disease  and  allow  it  to  run  its 
course.  All  depressing  agents,  as  the  mercurial 
preparations,  etc.,  are  thought  prejudicial  when 
given  for  their  peculiar  effect.  Quinine  has  not 
proved  itself  so  useful  in  controlling  the  febrile 
paroxysms,  as  might  have  been  supposed,  unless 
the  fever  shows  a  marked  remission.  Opium  in 
guarded  doses  is  found  invaluable  in  controlling 
the  looseness  of  the  bowels,  in  quieting  delirium 
and  inducing  sleep.  The  bowels,  when  a  tendency 
to  constipation  exists,  are  Ikept  soluble  by  the  mild 
cathartics,  as  rhubarb,  magnesia  or  castor  oil,  with 
a  little  turpentine ;  and,  as  debility  soon  makes  its 
appearance,  brandy,  commenced  with  early  and 
administered  with  judgment,  becomes  an  invalua- 
ble remedy.  Fluid  nourishment,  given  at  regular 
intervals  whether  the  patient  wishes  it  or  not,  is 
now  recognized  as  a  valuable  adjunct  in  the  treat- 
ment. The  action  of  all  the  secretory  and  excre- 
tory organs  must  be  inquired  into  from  day  to  day, 
and  any  irregularity  in  their  functions  must  be 
corrected  by  the  use  of  mild  remedies.  Frequent 
sponging  the  body  with  vinegar  and  water  cools 
the  skin  and  adds  much  to  bodily  comfort. 

There  is  another  disease  which  occurs  sporadi- 


DISEASES    OP    THIS    REGION.  15 

cally  in  the  cities  of  this  middle  region,  and  may 
even  show  itself  in  scattered  localities  when  in- 
duced by  specific  local  causes.  I  refer  to  Typhus 
Fever,  which  is  the  pest  of  armies,  occurring 
wherever  animal  accumulations  are  found  and 
known,  from  its  constantly  accompanying  armies, 
as  the  Camp  Fever.  As  its  causes  are  chiefly 
local  emanations  which,  in  spite  of  rigid  cleanli- 
ness, cannot  be  prevented  in  permanent  camps, 
the  difficulties  to  combat  this  disease  without  re- 
moval into  a  healthy  region  are  nearly  insurmount- 
able. Hence  the  frightful  mortality  which  renders 
this  the  plague,  when  it  appears  among  large  col- 
lections of  men.  In  civil  practice  debilitating 
remedies  cannot  be  borne — the  stronger  reasons 
for  rejecting  them  m  camp  medical  service.  All 
prostrating  treatment  must  be  sedulously  avoided.  Make 
stimulating  tonics  the  chief  dependence,  and  the 
best  results  will  be  obtained.  Quinine  may  be 
given  from  the  very  commencement  of  the  disease 
with  benefit.  Brandy  will  be  constantly  required, 
and  when  judiciously  and  regularly  administered, 
will  be  found  a  valuable  agent.  Giving  nourish- 
ing fluids  throughout  the  attacks,  and  restoring  or 
correcting  secretion  with  mild  medicinal  agents 
will  be  the  proper  course  to  pursue. 


CHAPTER    II. 

Material  of  Armies  Recruiting,  Clothing,  Food,  En- 
campments,  etc. 

Recruits. — In  times  of  peace  an  army  is  formed 
of  recruits,  who  are  enlisted  with  much  care.  Each 
individual  before  he  is  received  undergoes  a  criti- 
cal examination  by  the  recruiting  medical  officer, 
who  rejects  all  blemishes  as  well  as  those  condi- 
tions showing  a  predisposition  to  disease;  the 
object  gained  being  the  selection  of  a  body  of 
men  who,  from  physical  and  vital  perfection  of 
organization,  will  best  resist  external  morbid  in- 
fluences. Besides,  they  are  men,  whose  inclina- 
tions lead  them  to  pursue  a  life  to  which  they  are 
in  a  measure  fitted,  by  the  rough,  exposed  lives 
which  such  applicants  have  previously  led. 

Volunteers. — In  times  of  war,  especially  be- 
tween contiguous  countries,  where  national  ani- 
mosity rages  high,  entire  communities  rush  to 
arms  and,  with  one  accord,  adopt  camp  life  with 
its  exposures  and  trials.  Among  those  who  take 
up  arms  in  defence  of  their  rights  or  for  the  pro- 


MATERIAL    OF   ARMIES.  17 

tection  of  their  homes  and  families,  are  found  men 
from  every  position  in  life,  from  those  enjoying  the 
most  refined  and  cultivated  social  privileges,  to  the 
street  laborer,  all  having  a  common  cause  to  sup- 
port; men  of  every  variety  of  constitution,  tem- 
perament and  idiosyncrasy,  in  whom  every  form 
of  disease  is  found  lurking,  ready  to  show  itself 
upon  the  slightest  provocation.  Those  who  have 
led  lives  of  ease  and  luxury  are  suddenly  called 
up  to  assist  in  the  stern  and  laborious  duties  of 
the  soldier,  to  share  in  the  common  toil  and  to 
buffet  with  the  elements.  The  irregular  mode 
of  living  to  which  the  majority  are  totally  unac- 
customed, is  more  injurious  than  other  hardships 
which  they  daily  undergo,  to  the  sanitary  influ- 
ence of  which  they  owe  unwittingly  much  of  the 
health  which  soldiers  enjoy.  Exercise  in  the  open 
air  counteracts  many  of  the  would-be  injurious 
effects  of  exposure.  It  is  surprising  the  physi- 
cal improvement  which  the  gloved  members  of 
high  life  exhibit,  after  even  a  few  weeks'  cam- 
paign, when  followed  under  the  most  disadvan- 
tageous circumstances  of  inclement  weather. 

This  was  well  shown  among  the  troops  protecting 
the  batteries  in  the  neighborhood  of  Charleston  har- 
bor, prior  to  the  taking  of  Fort  Sumter.   When  the 
call  to  arms  was  made,  the  militia — composed  in  a 
2 


18  MATERIAL    OF    ARMIES. 

large  measure  of  clerks,  merchants  and  professional 
men,  most  of  whom  were  much  more  familiar  with 
the  duties  of  the  desk  than  manual  labor — with  one 
common  impulse  rushed  to  meet  the  enemy.  Many 
of  them  of  delicate  frames  and  frail  constitutions, 
exposed  themselves  upon  sandy  islands,  directly 
upon  the  sea  beach,  with  little  or  no  protection. 
They  were  badily  housed,  irregularly  fed  and  mis- 
erably watered.  Their  daily  duties  were  with  pick 
and  shovel  to  throw  up  redoubts,  establish  batteries 
and  mount  heavy  ordnance  during  the  day ;  whilst 
their  nights,  when  not  spent  in  anxiously  watching 
an  expected  invasion  or  performing  tedious  guard 
duty  during  a  spell  of  continuous  stormy  weather, 
was  forgotten  in  sweet  oblivion  upon  the  wet  sand, 
at  times  without  the  shelter  of  a  tent.  jSTotwith- 
standing,  the  sanitary  condition  of  the  troops  was 
excellent;  and  many,  of  delicate  frame,  returned 
to  their  homes,  at  the  expiration  of  two  months, 
sturdy,  robust  men,  with  an  addition  in  some  cases 
of  twenty-five  pounds  weight.  All,  without  excep- 
tion, were  improved  by  the  change  of  life,  under 
the  exhilarating  influence  of  sea  air  and  active 
exercise. 

It  has  been  often  noticed  that  soldiers,  taken 
from  the  better  classes  of  citizens,  go  through  cam- 
paigns of  great  exposure,  with  many  privations, 


MATERIAL    OF   ARMIES.  19 

much  better  than  the  heavily-built  yeomanry ; 
which  can  be  accounted  for  in  the  personal  care  of 
the  one  and  the  known  carelessness  of  the  other. 
All  armies  confirm  the  well-established  fact,  that 
raw  recruits,  in  the  field,  always  suffer  more  than 
veterans.  In  the  Crimea,  thousands  of  recruits 
filled  the  hospitals,  en  route,  before  arriving  at  the 
seat  of  war.  These  troops  had  been  selected,  indis- 
criminately, under  a  pressure.  Many  of  them  were 
young,  ill-conditioned,  undeveloped  in  body,  un- 
confirmed in  constitution,  and  hence  without  stam- 
ina or  powers  of  endurance.  When  compelled 
to  undergo  the  hardships  of  a  siege,  where  the 
strength  of  full-grown  men  soon  failed,  they  were 
very  quickly  used  up.  Unaccustomed  to  either 
the  work,  food  or  exposure,  to  which  they  were 
compelled  to  submit,  they  were  speedily  seized 
with  disease,  and  when  severely  attacked  they  usu- 
ally died  ;  or  if  they  survived,  their  convalescence 
was  painfully  prolonged,  and  the  least  imprudence 
produced  a  relapse.  An  English  Crimean  surgeon, 
in  speaking  of  the  character  of  the  troops  sent  to 
the  East,  and  of  the  hardships  which  they  sub- 
mitted to,  mentioned  to  me,  that  old  age,  decrepi- 
tude, with  feeble,  bent  frames,  wrinkled  faces  and 
grizzly  locks,  were  seen  in  youths  of  two  or  three 
and  twenty,  the  effect  of  two  winters'  toil,  want 
and  misery. 


20  STATISTICS    OF    KILLED    IN    MEXICO. 

In  examining  the  statistics  of  the  Mexican  war, 
we  find  this  well-established  rule  confirmed,  al- 
though the  material  of  which  the  volunteer  force 
was  composed  was  much  superior  to  the  average 
from  conscriptions  or  forced  enlistments.  The 
troops  sent  out  from  the  States  were  picked  men, 
well  developed  in  bodily  frame  and  constitution, 
yet  we  find  a  fearful  disparity  when  we  compare 
the  mortuary  reports  of  the  three  arms  of  the 
service. 

The  three  classes  of  troops  in  the  war  with  Mex- 
ico were  :  the  old  or  standing  army,  composed  of 
men  accustomed  to  the  fatigues  and  routine  of  a 
soldier's  life  ;  ten  regiments  of  enlisted  men,  care- 
fully selected  b}T  recruiting  surgeons  ;  and  73,000 
volunteers,  taken  at  random  from  all  walks  of 
life.*  The  total  loss  in  the  old  army,  by  deaths, 
discharges,  resignations  and  desertions,  exclusive 
of  discharges  by  expiration  of  service,  was  7,933, 
in  an  aggregate  force  of  15,736;  being  50.79  per 
cent,  for  the  whole  service  of  twenty-six  months, 
or  a  monthly  loss  of  1.95  per  cent.  In  the  ten 
new  regiments,  using  the  same  basis,  the  total 
loss  was  3,839,  in  an  .aggregate  strength  of  11,186  ; 
being  34.22  per  cent,  for  the  whole  service  of  fif- 
teen months,  or  a  monthly  loss  of  2.28  per  cent. 

*  Medical  Statistics  U.  S.  Army,  1839  to  1S5L 


STATISTICS    OF    KILLED    IN    MEXICO.  21 

In  the  regiments  and  corps  of  volunteers,  the 
total  loss  was  20,385,  in  an  aggregate  force  of 
73,260,  being  27.82  per  cent,  for  the  average  pe- 
riod of  service  of  ten  months,  or  a  monthly  loss 
of  2.78  per  cent.  When  it  is  remembered  that 
the  old  army  stood  the  brunt  of  all  the  early 
engagements,  and  that  many  of  the  volunteer 
regiments  were  never  in  battle,  the  dangers  of 
camp  life  to  volunteers  and  raw  recruits  become 
more  conspicuously  evident.  The  old  army  sus- 
tained a  loss  of  5.03  per  cent,  from  killed  in  battle 
or  dying  from  wounds — a  loss  of  792  men,  from 
15,736.  The  ten  new  regiments  met  with  a  loss 
of  143,  from  11,186,  or' 1.27  per  cent.  Whilst  the 
volunteer  corps,  numbering  73,260,  lost  in  battle 
and  from  wounds  only  613,  or  0.83  per  cent.,  whilst 
the  actual  sick  list,  carefully  compiled,  and  leaving 
out  all  losses  to  the  army  except  from  sickness, 
amount  to  15,617,  or  26.83  per  cent. 

These  statistics,  collected  with  great  care  by  the 
late  surgeon-general  of  the  United  States,  portray, 
in  vivid  colors,  the  effect  of  the  exposures  and 
hardships  of  an  active  campaign  upon  those  who, 
for  the  first  time,  adopt  the  life  of  a  soldier.  As 
not  only  the  valuable  lives  of  citizen  soldiery,  form- 
ing morally,  socially,  pecuniarily,  our  very  best 
people,  should   be  to  the  utmost   protected,  but 


22  STATISTICS    OF    KILLED    IN    MEXICO. 

also,  from  the  enormous  expense  and  trouble  in- 
curred by  a  nation  in  training  and  in  transporting 
an  army  for  distant  service,  it  is  imperative  that 
the  medical  staff  labor  to  disseminate  among  the 
troops  those  rules  of  hygiene  which,  when  consid- 
ered in  its  widest  sense,  are  so  profitable  in  sus- 
taining an  effective  military  strength. 

We  have  just  seen  that  in  our  own  wars,  as  in 
all  that  have  ever  occurred,  an  army  is  rarely  deci- 
mated by  the  fire  of  an  enemy.  Those  killed  in 
battle  are  but  a  handful  when  compared  to  the  vic- 
tims of  disease.  In  Mexico,  our  army  of  100,182 
men,  in  an  average  campaign  of  seventeen  months, 
exposed  to  the  continued  fire  of  an  enemy  who 
contested  every  inch  of  ground  from  the  seaboard 
to  their  capital,  making  a  firm  stand  at  every  stra- 
tegic point,  from  which  they  had  to  be  driven  under 
a  murderous  fire,  lost  but  1,549  men  in  battle  and 
from  wounds,  all  told;  whilst  10,986  died  in  Mex- 
ico from  disease,  besides  the  hundreds,  or  I  would 
be  well  within  bounds  when  I  say  thousands,  who 
returned  home  to  die  among  their  friends  from  the 
effects  of  diseases  contracted  in  camp.  For  some 
time  after  the  war,  volunteers  formed  a  noted  pro- 
portion of  the  inmates  of  civil  hospitals,  and  the 
chronic  diseases  under  which  they  were  laboring 
were  with  great  difficulty  controlled.  . 


RECRUITING    SERVICE.  23 

In  the  Crimean  service,  the  statistics  collected 
by  Lord  Panmnre,  minister  of  war,  show  the  Eng- 
lish loss  to  have  been  22,457,  of  which  number 
3,448  were  killed  in  battle,  or  died  from  the  effects 
of  wounds  received.  "Whilst  the  French  loss,  as 
reported  to  his  Government  by  M.  Scribe,  inspec- 
tor-general of  the  French  medical  service  in  the 
Crimea,  exhibits  the  frightful  loss  by  death  of 
63,000 ;  whilst  the  admission  into  hospital  num- 
bered 114,668. 

The  above  statistics  are  sufficient  to  show  that 
the  efficiency  of  an  army  does  not  consist  in  its 
great  numbers,  but  in  the  sanitary  condition  of 
the  troops. 

The  duties  of  the  medical  staff  are  paramount, 
as  the  nation  should  look  to  them  as  much  as  to 
the  military  leaders  for  the  successful  termination 
of  a  campaign.  Let  us  now  see  how  this  health, 
which  is  so  valuable  to  an  army,  can  be  preserved. 

Recruiting  Service. — The  first  protection  which 
an  army  has  is  in  the  recruiting  service,  which  is  a 
thorough  sifting  of  applicants  for  admission.  The 
duty  of  deciding  on  the  efficiency  of  a  recruit  de- 
pends upon  an  examination  made  hj  a  recruiting- 
officer  and  a  military  surgeon.  The  service  de- 
mands that  this  examination  be  thorough,  both  in 


24  RECRUITING    SERVICE. 

regard  to  moral  and  physical  disabilities.  The 
regulations,  therefore,  enjoin,  that,  "  in  passing  a 
recruit,  the  medical  officer  is  to  examine  him  strip- 
ped, to  see  that  he  has  free  use  of  all  his  limbs  ; 
that  his  chest  is  ample ;  that  his  hearing,  vision, 
and  speech  is  perfect ;  that  he  has  no  tumors,  ul- 
cerated or  extensively  cicatrized  legs  ;  no  rupture 
or  chronic  cutaneous  affection  ;  that  he  has  not 
received  any  contusion  or  wound  of  the  head  that 
may  impair  his  faculties ;  that  he  is  not  a  drunkard, 
is  not  subject  to  convulsions,  and  has  no  infectious 
or  other  disorder  that  may  unfit  him  for  military 
service.  The  surgeon  is  also  recmired  to  certify 
on  honor,  that  the  recruit  passed  by  him  "is  free 
from  all  bodily  defects  and  mental  infirmity,  which 
would  in  any  way  discmalify  him  from  performing 
the  duties  of  a  soldier."  As  the  recruit  must  be 
between  the  age  of  eighteen  and  thirty-five  years, 
at  least  five  feet  four  inches  in  height,  and  able- 
bodied,  we  can  understand  why  an  army  selected 
by  a  rigid  observance  of  the  above  regulations, 
composed  of  healthy,  robust  men,  in  the  vigor  of 
manhood,  when  brought  under  thorough  discip- 
line, is  in  the  best  condition  to  preserve  a  high 
standard  of  health. 

To  show  with  what  stringency  the  laws  on  this 
subject  are  observed,  we  give  the  recruiting  list  of 


CLOTHING  AND  FOOD  FOR  TROOPS.        25 

the  United  States  Army  for  1852.  The  total  num- 
ber examined  were  16,064,  of  these  13,338  were 
rejected  ;  2,726  were  alone  received  into  the  ser- 
vice. Among  the  causes  of  rejection  are  found 
the  following  :  jSTot  robust,  too  slender,  unsound, 
broken-down  constitutions,  general  unfitness,  im- 
becilit}T,  unsound  mind,  epilepsy,  intemperance 
and  bad  habits,  hernia  and  lax  abdominal  rings, 
varicose  veins  and  varicocele,  hemorrhoids,  syphilis, 
gonorrhoea,  loss  of  teeth,  unequal  length  of  limbs, 
general  and  local  malformation,  contracted  chest, 
spinal  curvature,  old  injuries,  fractures,  etc.;  cica- 
trices, tumors;  diseases  of  bones,  joints,  skin,  heart, 
testis,  and  tunica  vaginalis ;  of  arms,  eyes,  ears, 
glands,  chest,  throat  and  abdomen;  defective  hear- 
ing, speech  and  vision  ;  ulcers,  goitre,  ascetes  and 
anasarca,  obesity,  etc. 

"When  we  take  into  consideration  the  little  dis- 
parity of  age  with  the  absence  of  so  many  predis- 
posing causes  of  disease,  we  can  readily  see  why 
the  soldier,  by  profession,  has  so  great  an  advan- 
tage over  the  volunteer  force,  into  which  any  one 
capable  of  performing  duty  is  received,  however 
unfitted  he  may  be  physically  for  the  toil  and  pri- 
vations of  camp  life. 

To  obtain  the  utmost  capacity  of  labor  from 
3 


26        CLOTHING  AND  FOOD  FOR  TROOPS. 

men,  they  must  be  properly  clothed  and  well  fed. 
These  are  the  pre-requisites,  without  which  their 
powers  of  resistance  to  exposure  and  excessive 
exertion  are  not  developed.  A  soldier  is  com- 
pelled to  familiarize  himself  with  many  occurren- 
ces which  experience  in  actual  war  shows  to  he 
common.  He  is  often  called  upon  for  laborious 
work,  to  expose  himself  to  wind  and  rain,  heat 
and  cold,  to  suffer  hunger  and  fatigue,  to  travel  at 
night  as  well  as  during  the  day,  to  sleep  dressed 
and  accoutred  in  cloak  or  blanket.  He  must  be 
taught  when  thus  exposed"  to  secure  his  person 
from  disease,  and  to  ward  off  injurious  conse- 
quences. In  short,  he  ought  to  be  put  in  possession 
of  the  best  remedies  for  every  contingency  which 
may  or  can  happen  in  military  service.  This  is 
particularly  the  case  with  an  armed  body  who  may 
be  called  upon  at  any  moment  to  exert  great 
efforts  in  making  forced  niarches,  and,  under  many 
privations,  to  meet  a  bold  and  determined  enemy, 
and  to  repulse  a  superior  force.  The  strength  of 
an  army  is  calculated  rather  by  the  physique  of  its 
men  than  by  numbers,  as  experience  shows  that 
men  who  have  been  well  taken  care  of  are  capable 
of  opposing  successfully  double  the  force  badly 
provided.  To  preserve  health  and  efficiency, 
troops  must  be  well  clothed.     This  is  one  of  the 


THE    PHYSIOLOGY    OF    CLOTHING.  27 

weight}'  questions  in  the  economy  of  an  army,  and 
has  been  the  subject  of  much  study  and  experi- 
ment by  military  leaders. 

The  object  of  clothing  is  to  protect  the  skin 
from  diurnal  variations  or  annual  perturbations  of 
the  atmosphere,  whilst  it  absorbs  excretions,  and 
thus  becomes  the  means  which  allows  man  to 
enlarge  his  native  sphere,  and  successfully  resist 
extremes  of  temperature  in  the  torrid  or  frigid 
zones.  As  clothing  is  the  septum  placed  be- 
tween the  body  and  the  circumambient  air,  it  iso- 
lates by  retarding  the  transmission  of  caloric,  and 
thus  protects  in  proportion  to  its  powers  of  reflec- 
tion and  conduction.  These  properties  are- much 
modified  by  the  layer  of  air  which  is  shut  in  next 
to  the  skin,  as  also  by  that  which  permeates  the 
cloth,  filling  up  the  meshes  of  the  fabric,  this 
layer  of  air  being  known  to  be  a  bad  conductor. 
We  are  acquainted  with  a  familiar  application  of 
this  law  in  the  bitter  coldness  of  a  windy  day,  when 
compared  with  the  comfort  of  much  colder  but 
quiet  weather.  It  is  the  action  of  these  causes 
which  explains  why  the  exterior  of  the  clothing  of 
a  soldier,  bivouacked  without  shelter  under  the 
clear  sky,  is  colder  than  the  surrounding  air.  As 
bad  conductors,  the  heat  which  escapes  from  the 
skin  traverses  slowly  the  thickness  of  clothing,  but 


28         THE  PHYSIOLOGY  OF  CLOTHING. 

as  soon  as  it  reaches  the  external  surface,  it  is 
radiated  or  emitted  rapidly.  The  protection  of  a 
tent  or  even  a  cloak  counteracts  this  radiation. 
The  inverse  protection  which  the  blanket  gives 
the  Spaniard  or  Arab  in  hot  weather,  is  similarly 
accounted  for.  The  radiating  properties  of  wool 
exceeds  its  conducting  or  absorbing  powers,  and 
throws  off  the  great  heat  of  the  sun  before  it  can 
penetrate  the  thickness  of  clothing  and  reach  the 
wearer's  skin. 

Besides  the  property  just  enumerated,  the  hy- 
grometric  powers  of  different  fabrics,  condensing 
moisture  from  the  air  and  absorbing  perspiration, 
are  of  much  importance  in  the  sanitary  economy 
of  clothing.  In  either  case  their  power  of  con- 
ducting heat  is  increased,  and  therefore  the  more 
moisture  they  contain  in  their  meshes  the  colder 
they  are  as  apparel.  The  fluid  which  the  cloth 
imbibes  takes  the  place  of  air,  and  becomes  a 
cause  of  refrigeration  by  evaporation,  robbing  the 
neighboring  skin  of  its  heat  to  form  aqueous 
vapor.  Linen,  for  instance,  imbibes  at  once  mois- 
ture from  any  source,  and  chills  the  body  by 
the  evaporation  of  this  moisture ;  this  material 
for  articles  of  clothing  exposes  the  body  to  sensa- 
tions of  cold  and  dampness,  and  necessarily  to  the 
diseases  which  are  brought  on  by  such  exposure. 


THE    PHYSIOLOGY    OF    CLOTHING.  29 

Cotton  fabrics,  although  not  so  attractive  to  mois- 
ture, permits  absorption  and  evaporation  to  a 
considerable  extent.  Whilst  woollen  goods  con- 
denses moisture  as  badly  as  it  conducts  heat,  from 
it  evaporation  goes  on  very  gradually,  so  as  scarcely 
to  chill  the  external  surface  of  the  clothing. 

The  hygrometric  properties  of  clothing  are  inti- 
mately connected  with  their  action  upon  the  skin, 
when  considered  as  an  organ  of  absorption  and 
excretion.  Cutaneous  perspiration  varies  in  quan- 
tity, according  to  the  powers  of  conduction,  radia- 
tion, and  heat-absorbing  properties  of  clothing, 
which  cannot  modify  the  heat  exhalation,  absorp- 
tion and  sensibility  of  the  skin  without  reacting 
upon  its  functions.  The  energy  of  cutaneous 
elimination  regulates  in  a  measure  the  march  of 
other  excretions.  Anything  which  impresses  the 
nerves  of  the  skin  excites  equally  the  origin  of 
these  nerves,  and  causes  exaltation  or  depression 
of  the  system.  Clothing  determines  the  antago- 
nism which  exists  between  animal  heat  and  ex- 
ternal temperature.  The  source  of  animal  heat 
increases  or  diminishes  its  activity  according  to 
changes  in  the  atmosphere ;  but  the  unequal  pro- 
duction of  heat  causes  corresponding  oscillations 
in  the  movements  of  respiration  and  circulation  in 
the  action  of  the  muscles  and  the  brain.    Clothing 


OU  CLOTHING    OF    TROOPS. 

affects,  then,  all  the  functions  of  the  economy,  and 
may  clearly  represent  the  question  of  health. 

As  the  object  of  clothing  is  usefulness  and  con- 
venience, the  best  uniform  is  that  which  will  pro- 
tect the  body  from  the  inclemencies  of  the  weather, 
and  which  least  impedes  the  movements  which  are 
connected  with  military  duties.  Experience  in  the 
field  teaches  what  can  be  dispensed  with  or  what 
can  be  added  with  advantage.  The  clothing  se- 
lected depends  much  upon  the  habits  of  a  people 
and  the  country  in  which  the  war  is  carried  on. 
We  can  readily  understand  how  absurd  it  would 
be  in  the  English  Government  sending  their  home 
troops  in  their  thick  red  coats,  leathered  necks  and 
shakoed  heads  to  do  field  duty  on  the  scorching 
plains  of  India.  There  are  certain  portions  of  the 
clothing  which  experience  shows  conducive  to 
health  in  all  countries  and  under  every  circum- 
stance. The  clothing  for  troops  should  be  made 
of  wool,  whether  the  material  be  heavy  or  light,  to 
suit  the  climate. 

The  sold/'er'.s  coat  should  be  a  frock  fitting 
loosely,  easy  over  the  shoulders,  with  full  play  for 
the  arms,  without  binding  in  any  way,  and  wide  in 
the  body,  so  as  not  to  impede  the  expansion  of  the 
chest  when  closely  buttoned.  The  tail  of  a  coat 
gives  much  protection  to  the  body  and  abdomen 


CLOTHING    OF    TROOPS.  31 

from  damp,  whilst  a  jacket — which  is  a  very  poor 
costame  for  soldiers — exposes  the  entire  body  to 
drafts  and  dampness,  fruitful  causes  of  bowel  com- 
plaints. The  trousers  should  be  of  good,  heavy 
woollen  material,  made  also  free,  for  the  easy  play 
of  the  limbs.  Flannel  shirts,  coming  well  down 
upon  the  thighs,  and  drawers  of  the  same  material, 
are  of  great  hygienic  utility.  In  winter  they  retain 
the  animal  heat  and  support  the  health}7  function 
of  the  skin,  whilst  in  summer  they  absorb  more 
readily  the  excess  of  perspiration,  which  occurs 
under  severe  exercise ;  and  whilst  agreeable  to  the 
wearer,  they  prevent  sudden  arrests  of  perspira- 
tion, and  are  thus  a  protection  against  diarrhoea 
and  dysentery,  which  are  so  fatal  to  armies. 
These  should  be  furnished  in  sufficient  numbers 
to  enable  the  soldier  to  change  when  he  has  been 
exposed  to  rain,  as  he  may  thus  prevent  pneu- 
monias and  bronchial  affections,  so  common  to 
camp  life. 

In  the  French  service,  where  flannel  under- 
clothing is  not  in  that  constant  use  as  in  the 
English  and  American  service,  every  soldier 
carries  a  band  of  flannel,  with  which  he  envelops 
his  abdomen,  as  a  safeguard  from  abdominal  affec- 
tions. Baudens,  one  of  the  surgeons-in-chief  of 
the    Crimean   service,    speaks    of    this    band    as 


32  CLOTHING    OF    TKOOPS. 

essential  to  the  health  of  the  troops,  and  refers 
to  the  much  better  and  more  convenient  pro- 
tection which  the  English  flannel  shirt  gives 
to  the  men.  The  liability  of  losing  the  flan- 
nel girdle,  and  its  very  partial  protection,  is  a 
serious  objection  to  its  use.  For  similar  rea- 
sons woollen  socks  should  always  be  given  to  sol- 
diers. They  are  much  more  durable  than  cotton, 
and  much  more  healthy,  preserving  an  equal  tem- 
perature and  retaining  warmth  to  the  feet  which, 
being  at  the  greatest  distance  from  the  centre  of 
the  circulation,  are  least  capable  of  resisting  cold, 
and,  therefore,  require  most  protection  against  in- 
jury. They  also  afford  a  better  protection  against 
the  chance  of  blistering  than  socks  of  other  mate- 
rial. 

The  feet  are  part  of  the  person  of  a  soldier  so 
essential  for  the  performance  of  military  duty, 
that  their  condition  should  be  particularly  attend- 
ed to  by  the  oflicers.  The  shoes,  boots  or  half-boots 
should  be  well  made,  of  good,  durable  material, 
and  well  fitted  to  the  foot,  so  as  to  be  easy  to  the 
wearer.  The  soles  should  be  broad,  thick  and 
firm,  high  quartered  so  as  to  exclude  mud  or  sand? 
and  closely  fitting  around  the  instep,  so  that  tena- 
cious clay  cannot  easily  drag  it  from  the  foot.  A 
o-ood  shoe  or  boot  adds  often  as  much  to  the  effi- 


CLOTHING    OF   TROOPS.  33 

ciency  of  the  soldier  as  a  good  weapon.  Marching 
is  as  necessary  a  quality  as  fighting,  and  is  made 
one  of  the  requisites  in  becoming  a  member  of  the 
Imperial  Guard  of  the  present  French  Emperor. 
When  the  shoe  does  not  fit  the  wearer  who  is 
compelled  to  use  them,  sore  feet,  a  very  trouble- 
some complaint  in  the  army,  is  brought  on.  In 
the  march  men  are  found  lagging  behind  from 
lameness,  and,  as  these  are  exposed  to  be  cut  off 
by  marauders,  it  is  the  duty  of  those  in  authority 
never  to  deliver  a  pair  of  shoes  which  have  not 
been  tried  with  care.  The  leather  should  be  well 
smeared  with  grease,  oil,  wax,  tallow  or  other  com- 
position to  make  them  water-proof  and  soft.  This 
should  be  done  daily  in  wet  weather.  In  the 
Crimean  service  the  Russian  half-boot  was  found 
so  superior  an  article  over  the  boots  or  shoes  of 
the  Allies,  that  they  were  sought  for  Avith  avidity 
upon  the  dead  as  soon  as  they  were  shot  down, 
and  were  more  prized  than  any  other  article  of 
wearing  apparel,  so  conducive  were  they  to  the 
comfort  of  the  wearer.  They  protected  the  feet 
perfectly  from  the  mud  in  which  the  troops  lived 
for  months. 

The  French  gaiter  used  in  the  Crimea,  was 
made  of  heavy  white  cloth,  covering  two-thirds 
of  the  foot  and  extending  some  distance  up  the 


d4  CLOTHING   OF   TROOPS. 

leg,  usually  over  the  knee.  It  facilitates  walking, 
and  prevents  enlargement  of  the  veins,  whilst  it 
protects  the  limb  from  cold  and  wet.  Experience 
in  the  field  and  upon  the  march  has  proved  them 
so  serviceable  that  the  entire  French  army  is  pro- 
vided with  them.  They,  as  a  substitute  for  the 
boot,  might  be  added  with  advantage  to  the  equip- 
ment of  the  soldier.  "When  made  of  leather  they 
become  hard  after  getting  wet  and,  by  pressure, 
excoriate  the  ankles.  Beside  which,  the  leather 
is  cold  in  winter  and  very  hot  in  summer.  The 
only  advantage  in  the  leather  gaiter  is  durability; 
the  cloth  wears  out  much  sooner,  and  also  becomes 
saturated  with  moisture  in  very  wet  weather.  In 
addition  to  the  gaiter,  many  of  the  French  troops 
wear  greaves  made  of  heavy  patent  leather,  which 
cover  the  leg  to  the  knee,  shutting  in  the  bottom 
of  the  pants.  This  gives  them  great  facilities  in 
walking,  as  it  protects  the  leg  of  the  pantaloon 
from  becoming  foul  with  mud,  which  is  an  endless 
annoyance  to  troops  marching  in  bad  weather. 
Every  soldier  should  have  an  overcoat  of  stout 
cloth,  reaching  below  his  knees,  with  a  cape  cov- 
ering the  shoulders.  This,  like  all  other  articles 
of  clothing,  should  be  made  eas}?-,  to  permit  of 
any  movements  without  binding.  The  French 
have   added    a    hood,    to    protect  the   head   and 


CLOTHING    OP    TROOPS.  35 

neck  in  bad  weather  from  cold,  wind  and  rain, 
which  diminishes  the  frequency  of  catarrhal  affec- 
tions. When  on  guard'  duty  in  bad  weather  they 
arc  of  great  utility,  and  protect  the  head  and  neck 
from  the  damp  ground  when  sleeping.  Crimean 
soldiers  found  this  addition  a  great  improvement. 

In  selecting  a  color  for  a  uniform,  it  should  be 
remembered  that  light  colors  absorb  less  than 
dark,  and  also  that  odoriferous  exhalations  adhere 
with  much  greater  pertinacity  to  dark  than  to 
light  clothing,  which  is  an  item  of  no  small  im- 
portance when  the  deleterious  emanations-  ac- 
companying large  bodies  of  men  are  considered. 
Beside  which,  experience  in  battle  shows  that 
certain  colors  make  much  better  marks  to  fire  at 
than  others;  and,  according  to  calculations,  a 
soldier  dressed  in  light  cloth  is  much  less  liable 
to  be  hit  than  in  dark.  The  following  is  the  pro- 
portion: red,  twelve;  rifle  green,  seven;  brown, 
six ;  Austrian  bluish  gray,  five.  Eed,  which  is  the 
most  attractive  and  fatal  color,  is  more  than  twice 
as  much  so  as  gray,  which  is  the  least. 

The  best  military  hat  in  use  is  a  light,  soft  felt, 
with  a  sufficiently  high  crown  to  allow  space  for 
air  over  the  brain.  The  rim  can  be  fastened  up  in 
fair  weather;  and,  when  turned  down,  protects,  in 
a  measure,  from  the  rain  or  from  the  rays  of  the 


36  CLOTHING    OF    TROOPS. 

sun.  In  a  warm  climate,  the  light  color  of  the 
hat  adds  much  to  the  comfort  of  the  wearer.  The 
small,  jauntily-fitting  kelpe  is  light,  but  does  not 
protect  the  face;  and,  when  made  of  dark  mate- 
rials, concentrates  the  solar  rays  upon  the  head. 
This  can  be  obviated  by  adding  a  Havelock,  which 
consists  of  a  cap  cover  with  a  long  cape  attached, 
and,  hanging  down  upon  the  shoulders,  protects 
the  neck  from  the  sun  in  the  day  and  draughts  at 
night.  It  is  made  of  light  cloth,  of  a  light  color, 
for  reflecting  heat.  Those  who  have  worn  them 
on  a  march,  or  when  exposed  to  the  sun's  rays, 
speak  in  extravagant  terms  of  the  comfort  and 
protection  which  they  give.  The  advantage  of  a 
light  and  high-crowned  hat  is,  that  when  exposed 
to  the  sun,  on  a  march,  a  small,  wet  handkerchief 
placed  in  the  crown  will  not  only  prevent  sun- 
stroke, but  will  add  much  to  the  comfort  of  the 
soldier. 

According  to  the  army  regulations  of  the  Con- 
federate service,  a  soldier  is  allowed  the  uniform 
clothing  stated  in  the  following  table,  or  articles 
thereof  of  equal  value : 


CLOTHING    OF    TROOPS. 


37 


CLOTHING. 


Cap,  complete, 
cover.  .  . . 
Coat 


Trousers 

Flannel  shirt 

Flannel  drawers 

Bootees,*  pairs 

Stockings 

Leather  stock 

Great  coat 

Stable  frock  (for  mounted  men) 

Fatigue   overall  (for  engineers  and  ordnance) 
Blanket 


FOR  THREE  TEARS. 


Total 

for 

three 

years. 


In  the  field,  there  should  be  always  a  supply  of 
clothing  at  hand,  to  replace  unavoidable  accidents. 
During  the  Crimean  service,  Dr.  McLeod  informs 
us  that  the  deficiency  of  clothing,  which  was  so 
much  complained  of,  was  one  of  the  most  prolific 
sources  of  subsequent  disease  among  the  English 
troops.  One  of  the  maxims  for  preserving  health 
in  a  campaign  is,  that  soldiers  must  protect  themselves 
in  summer  from  night  air  by  warm  clothing.  A  heavy 
blanket,  not  in  name,  but  in  weight,  and  one  and 
a  half  yards  of  india-rubber  cloth,  complete  the 
furnishing  of  a  soldier.  The  india-rubber  cloth 
is  a  waterproof  covering  for  him  during  exposure, 
and  will  always  make  for  him  a  dry  bed,  upon 
which  he  can  find  health  as  well  as  comfort. 


*  Mounted  men   may   receive   one  pair  of  "boots"  and   two  pair   of 
'bootees,"  instead  of  four  pair  of  bootees. 


db  CLOTHING    OF    TROOPS. 

.  We  make  the  following  extract,  on  the  extent  of 
a  soldier's  equipment,  from  Jackson's  Formation, 
Discipline  and  Economy  of  Armies.  In  the  form 
and  fashion  of  a  soldier's  equipment,  "the  adjust- 
ment of  the  kind  and  quantity  of  articles  termed 
necessaries  is  a  matter  of  importance,  and  as  such 
requires  to  be  well  considered.  It  is  demonstrably 
proved  to  the  conviction  of  all  persons  who  have 
served  with  armies,  that  superfluous  baggage,  that 
is,  baggage  beyond  the  narrowest  measure  of  util- 
ity, instead  of  bringing  comfort  to  the  possessor, 
is  a  cause  of  great  annoyance  and  vexation.  A 
complete  change  of  the  smaller  parts  of  dress,  in 
the  event  of  being  wet  with  rain,  together  with  a 
cloak  as  a  covering  for  the  night,  is  all  that  a  sol- 
dier requires  for  his  comfort  and  the  preservation 
of  his  health;  and,  as  such,  it  is  all  that  he  ought 
to  be  permitted  to  possess.  Where  persons  have 
not  more  than  one  change  of  raiment,  the  strong 
impression  of  necessity  obliges  them  to  prepare 
for  the  return  of  want.  Where  there  is  a  super- 
fluity, the  necessity  does  not  present  itself  so  forci- 
bly, and  hence  the  dirty  clothes  are  crammed  into 
the  knapsack,  where  they  accumulate  in  quantity 
without  obliging  the  individual  to  recollect  that 
they  are  not  fit  for  use  until  they  are  washed.  It 
thus  often  happens  that  a  soldier  who  has  four  or 


EQUIPMENT    OF   A    SOLDIER    FOR    SERVICE.  39 

more  shirts  in  his  possession,  has  not  one  fit  for 
use,  while  a  soldier  who  possesses  no  more  than 
two  has  generally  one  in  his  knapsack  ready  for 
the  contingent  occasion." 

The  following  is  considered  to  he  a  full  equip- 
ment for  a  soldier  on  service,  namely :  two  shirts, 
flannel  preferable  ;  two  pair  of  woollen  socks;  two 
pair  of  flannel  drawers ;  two  pair  of  shoes,  or  one 
pair  of  shoes  and  one  of  half  boots ;  one  pair  of 
gaiters ;  a  small  case  of  needles,  thread  and  but- 
tons for  mending  clothes ;  small  shoe  brush,  with 
blacking ;  comb  and  hair  brush ;  one  piece  of 
soap  ;  a  sponge  for  washing  the  body,  and  a  towel 
tor  drying  it ;  two  pocket  handkerchiefs  ;  an  over- 
coat of  heavy  materia],  besides  his  uniform.  He 
should  also  have  a  heavy  blanket,  better  if  lined 
with  stout  osnaburgs  to  increase  its  durability  and 
warmth,  and  two  yards  of  india-rubber  cloth  to 
protect  him  from  the  weather.  He  should  also 
carry  a  knife,  fork  and  spoon,  a  canteen  for  drink, 
and  also  a  canteen  or  haversack  for  carrying 
dressed  provisions.  If  those  articles  of  clothing 
not  in  use  be  put  up  in  a  neat  and  compact  man- 
ner and  enveloped  in  oiled  silk,  so  as  to  be  secure 
from  wet,  and  deposited  in  the  knapsack  for  easy 
carriage,  the  soldier  will  not  be  incommoded  by 
the  bulk  or  encumbered  by  the  weight ;  and  pos- 


40  PERSONAL    CLEANLINESS. 

sessing  within  himself  everything  actually  neces- 
sary for  use,  will  be  independent  of  the  accidents 
so  common  to  the  baggage  wagons. 

In  'the  above  list  we  have  purposely  omitted 
shaving  apparatus,  as  every  soldier  in  the  field 
should  allow  his  beard  to  grow.  It  protects  his 
throat,  and  often  prevents  lung  diseases,  catarrhal 
affections,  etc.  A  heavy  moustache  is  known  to 
protect  the  wearer,  to  a  certain  extent,  from  mala- 
rial influences,  acting  as  a  sieve  to  the  lungs.  It 
also  purifies  the  atmosphere  inhaled,  of  dust  dur- 
ing marches,  and  thereby  prevents  many  trouble- 
some diseases.  Cleanliness  dictates  that  the  hair 
be  cut  close  on  the  head,  and  although  the  beard 
be  allowed  to  grow,  it  should  also  be  kept  within 
bounds. 

Cleanliness. — Nothing  contributes  more  to  pre- 
serve health  than  personal  cleanliness  ;  and  as  the 
free  use  of  soap  is  a  prophylactic  as  well  as  a 
civilizer,  it  should  be  regularly  distributed  to  the 
men.  Daily  ablutions  should  never  be  omitted ; 
and,  if  possible,  the  chest  and  arms,  as  well  as  the 
face  and  neck,  should  be  well  sponged.  Baths 
should  be  used  whenever  opportunity  permits. 
Keeping  the  skin  clean  prevents  fevers  and  bowel  com- 
plaints in  warm  climates.  Baudens,  in  insisting  upon 
cleanliness,  says  "  that  the  contrast  in  the  sickness 


FOOD.  41 

and  mortality  of  the  English  and  French  camp  in 
the  Crimea,  can  be  in  a  measure  attributed  to  the 
frequent  ablutions  of  the  English,  who  washed 
their  clothes  in  hot  water,  and  changed  „their 
underclothes  twice  a  week.  It  is  easy  to  under- 
stand how  carelessness  in  this  respect  will  impair 
the  functions  of  the  skin  and  induce  disease.  At 
review,  our  French  soldiers  show  new  clothes,  and 
on  the  whole  an  unquestionable  military  equip- 
ment, yet  these  beautiful  battalions  leave  in  their 
passage  a  strong  smell  of  barracks  not  to  be  mis- 
taken." 

It  should  be  the  duty  of  the  medical  officer  to 
suggest  to  the  commanding  officer  to  insist  that 
these  hygienic  regulations  be  rigidly  enforced. 
He  is  not  only  the  best,  but  also  the  most  popular 
officer,  who  attends  himself  to  the  detailed  com- 
forts of  his  men. 

Food  of  the  soldier  should  be  plain,  nutritious 
fare,  well  cooked,  which,  with  exercise  as  an  appe- 
tizer, he  finds  no  difficulty  in  enjoying,  however 
monotonous  his  daily  ration  may  be.  For  a  work- 
ing man  (and  where  do  men  labor  more  than  the 
soldier  in  the  field?)  the  diet  should  be  of  a  mixed 
character,  and  food  should  be  of  the  variety  easily 
cooked.  The  fundamental  rule  in  the  culinary  art 
is  boil  slowly,  and  roast  quickly.  Highly  seasoned 
4 


42  FOOD. 

dishes  are  neither  possible  nor  desirable  for  the 
soldier.  Toil,  fatigue,  and  often  hunger,  will 
make  any  wholesome  food  savory.  "The  plain 
repast  is  sufficient  for  sustenance ;  and  a  plain 
repast  gives  all  the  gratification  to  the  palate  of 
a  hungry  and  thirsty  man  that  a  soldier  ought 
to  permit  himself  to  receive."* 

For  the  English  there  is  no  beverage  as  tea; 
and  a  military  writer  remarks,  that  a  breakfast  of 
tea  with  bread,  enables  a  person  to  sustain  the 
fatigues  of  war  with  more  energy  and  endurance 
than  a  breakfast  of  beefsteak  and  porter.  The 
French  prefer  coffee,  to  which  they  give  the 
highest  prophylactic  virtue.  This  is  the  stimula- 
ting drink  of  the  troops,  and  its  free  use  makes 
the  men  much  more  healthy  and  cheerful.  It  is 
at  all  times  an  excellent  substitute  for  alcoholic 
beverages,  which  disorganize  an  army  by  tempt- 
ing to  drunkenness.  Whiskey  should  only  be 
given  out  to  men  on  very  exposed  duty,  or  in 
very  bad  weather,  and  it  is  a  question  whether  a 
cup  of  hot  coffee  is  not  preferable  even  under 
these  circumstances.  The  Turks  place  great 
reliance  on  coflee  as  a  preservative  against  dys- 
entery ;  and  McLeod  states  as  a  result  of  his 
Crimean  experience  :  "  I  have  no  doubt  that  if  the 

*  Jackson,  Economy  of  Armies. 


FOOD.  43 

precaution  had  been  taken  to  supply  the  troops 
every  morning  with  hot  coffee,  as  they  went  on  or 
returned  from  duty,  much  of  our  mortality  might 
have  been  avoided." 

As  roasted  and  ground  coffee  has  become  a  fixed 
article  of  trade,  it  would  be  much  better  for  the 
troops  if  it  could  be  served  out  in  this  form,  par- 
ticularly when  they  are  upon  extra  fatigue  duty, 
as  it  not  only  saves  them  much  time,  but  insures 
the  proper  preparation  of  a  supporting  beverage. 

It  may  be  needless  to  say  that  good  water  is 
even  more  necessary  than  good  food,  and  should 
be  obtained  at  any  cost  for  the  use  of  the  troops. 
There  is  no  one  item  so  prolific  in  disease  as 
drinking  bad  water.  Should  troops  be  so  unfor- 
tunate as  to  be  in  a  place  where  stagnant  or  ditch- 
water  has  to  be  used,  it  can  be  purified  by  boiling 
with  a  lump  of  charcoal ;  after  which  it  should  be 
freely  agitated  in  the  air  to  restore  to  it  the  vivify- 
ing properties  which  the  heat  had  driven  off. 

Fresh  meat  and  vegetables  should  be  served  out 
to  troops  whenever  they  can  be  had,  and  the  best 
mode  of  cooking  them  is  in  soup.  A  French  mili- 
tary proverb  says  that  "  soup  makes  the  soldier." 
The  free  use  of  fresh  vegetables  is  the  only  mode 
of  preventing  the  appearance  of  scurvy  among 
the  troops.     When  these  cannot  be  obtained,  the 


44  FOOD. 

free  use  of  dried  vegetables,  as  rice,  potatoes,  corn- 
meal,  etc.,  will  tend  to  sustain  health  and  vigor. 
In  the  Crimea,  where  the  temporary  absence  of 
fresh  vegetables  was  a  great  and  serious  privation, 
lime  juice,  citric  acid  and  sour-crout,  were  exten- 
sively used  to  prevent  and  to  stop  scurvy. 

Acid  fruits  are  anti-scorbutic,  and  very  good  for 
soldiers.  The  English,  in  the  Crimea,  gave  out  a 
ration  of  lemon  juice  three  times  a  week,  which, 
when  mixed  with  rum  and  sugar,  made  a  very 
nice  and  healthy  drink.  This  corrective  protected, 
comparatively,  the  English  soldiers  from  scurvy, 
whilst  with  the  French  it  was  widely  epidemic 
and  very  fatal.  Vinegar,  when  freely  distributed, 
also  assists  in  preventing  this  scourge  among 
troops.  Vinegar,  molasses  and  water,  when  mixed 
in  proper  proportions,  make  a  very  refreshing  and 
palatable  drink,  not  unlike  lemonade,  and  pos- 
sessing similar  anti-scorbutic  properties  to  lemon 
juice.  A  distinguished  military  surgeon  has  re- 
marked that  100,000  francs  spent  in  fresh  vegeta- 
bles, will  save  500,000  francs  from  the  expenses  of 
sick  soldiers  entering  the  hospital,  besides  the  use 
of  the  men  for  active  service.  Of  the  dried  vege- 
tables, rice  is  the  best  for  feeding  troops.  It  is 
easily  carried,  easily  cooked,  easily  digested,  and 
is  the  most  wholesome  of  the  farinaceous  articles, 


RATIONS.  "  45 

correcting  intestinal  fluxes.  Biscuits,  or  hard 
bread,  is  a  common  article  of  diet  in  camp  life,  be- 
cause it  is  easily  preserved  and  transported.  When 
eaten  as  dry  biscuit,  it  acts  like  a  sponge  in  the 
mouth,  exhausting  salivary  secretion,  and,  tiring 
the  jaws,  it  produces  surfeit.  "When  possible,  and 
rarely  is  it  not  convenient,  soak  it  in  tea,  coffee 
or  sonp ;  it  then  makes  a  very  nutritious  meal. 
Even  water,  with  a  little  salt,  makes  it  much  more 
palatable  and  nourishing.  Fresh  bread  is  alwa}Ts 
preferable  when  it  can  be  obtained. 

Bacon  is,  par  excellence,  the  laborers'  and  sol- 
diers' meat  in  America,  and  goes  further,  by 
weight,  than  any  other.  It  never  produces  sur- 
feit, is  always  acceptable,  very  easily  cooked,  and 
with  its  rich  juice  will  make  the  dryest  farina- 
ceous diet  savory.  It  has  the  very  great  advan- 
tage of  keeping  for  any  length  of  time,  under 
any  condition,  which  makes  it  far  preferable  to 
any  other  meat  for  troops. 

In  the  Confederate  service  the  ration  consists  of 
three-quarters  of  a  pound  of  pork  or  bacon,  or 
one  and  one-quarter  pounds  of  fresh  or  salt  beef; 
eighteen  ounces  of  bread  or  flour,  or  twelve  ounces 
of  biscuit,  or  one  and  one-quarter  pounds  corn 
meal ;  and  at  the  rate,  to  one  hundred  rations,  of 
eight  quarts  of  peas  or  beans,  or  in  lieu  thereof, 


46  THE    MESS. 

ten  pounds  of  rice,  six  pounds  of  coifee,  twelve 
pounds  sugar ;  also,  four  quarts  of  vinegar.  The 
ration  is  completed  by  adding  one  and  one-half 
pounds  of  tallow,  one  and  one-quarter  pounds  ada- 
mantine, or  one  pound  sperm  candles,  four  pounds 
soap,  and  two  quarts  salt  to  one  hundred  rations. 
On  a  campaign,  or  on  marches,  or  on  board  trans- 
ports, the  ration  of  hard  bread  is  one  pound. 

When  the  officers  of  the  medical  department 
find  anti-scorbutics  necessary  for  the  health  of  the 
troops,  the  commanding  officer  may  order  issues 
of  fresh  vegetables,  pickled  onions,  sour-crout  or 
molasses,  with  an  extra  quantity  of  rice  and  vine- 
gar ;  potatoes  are  usually  issued  at  the  rate  of  one 
pound  per  ration,  and  onions  at  the  rate  of  three 
bushels  in  lieu  of  one  of  beans.  Occasional'ssues 
(extra)  of  molasses  are  made — two  quarts  to  one 
hundred  rations;  and  of  dried  apples,  of  from  one 
to  one  and  a  half  bushels  to  one  hundred  rations. 

As  soldiers  are  expected  to  cook  their  own  pro- 
visions, and  as  all  are  familiar  with  the  fact  that 
as  much  depends  upon  the  mode  of  cooking  as 
upon  the  articles  cooked,  it  would  be  better  to 
have  special  cooks  in  each  mess  than  to  allow  the 
soldiers  to  cook  in  turn.  A  division  of  labor  is 
clearly  the  preferable  plan.  Firewood,  of  course, 
must  be  liberally  provided,  as  it  is  one-half  of  a 
soldier's  existence. 


THE    MESS.  47 

The  entire  health  of  troops  depends  upon  the 
quality,  quantity,  variety,  and  the  regularity  with 
which  the  provisions  are  supplied.  The  effect- 
ive condition  and  strength  of  the  army,  with  a 
diminution  of  the  sick,  and  consequently  a  dimi- 
nution in  the  hospital  expenses,  will  depend  in  a 
great  measure  upon  the  commissary  department. 
In  1847  the  dearness  of  provisions  doubled  the 
number  of  sick  in  the  French  arary,  sending  one- 
fifth  of  the  effective  regiments  into  the  hospitals. 
The  better  paid,  select  corps,  who  could  increase 
their  supply  of  nourishment,  escaped  those  dis- 
eases which  ravaged  the  common  soldier. 

Officers  and  soldiers  usually  club  together  into 
messes,  as  this  living  together  is  not  only  much 
more"  agreeable,  but  also  profitable  for  all  con- 
cerned. The  following  appears  to  have  been 
compiled  by  an  experienced  soldier : 

"  Officers'  messes  should  consist  of  the  company 
officers — four  persons.  The  colonel,  lieutenant- 
colonel,  major,  adjutant  and  sergeant-major,  with 
the  commissary,  quartermaster,  surgeon,  assistant 
surgeon  and  chaplain,  could  easily  arrange  two 
messes. 

"  Messes  of  privates  and  non-commissioned  offi- 
cers should  number  six  persons,  for  obvious  rea- 
sons, so  that  the  details  for  guard  duty  would 
always  leave  four  in  charge  of  the  tent. 


48  the  mess; 

"Articles  wanted  for  a  mess  of  six:  Two  cham- 
pagne baskets,  covered  with  coarse  canvas,  with 
two  leather  straps  with  buckles,  six  tin  plates,  six 
tin  cups,  six  knives  and  forks,  six  bags  for  sugar, 
coffee,  salt,  etc.,  to  hold  from  half  a  gallon  to  one 
gallon,  one  large  size  camp  kettle,  one  iron  pot, 
one  bake  oven,  one  frying  pan,  one  water  bucket, 
one  lantern,  one  coffee  mill,  six  spoons,  one  tin 
salt  box,  one  tin  pepper  box,  two  butcher  knives, 
tAVO  kitchen  spoons,  two  tin  dippers,  one  tea  pot, 
one  coffee  kettle." 

It  is  always  a  good  rule  to  accustom  an  army  to 
adopt  the  modes  of  living  common  to  the  inhabi- 
tants of  the  country  in  which  the  army  is  found, 
as  certain  peculiarities  of  living  naturally  adapt 
themselves  to  certain  climates. 

Although  war  brings  with  it  privations  and 
irregular  living,  which  it  is  impossible  to  prevent, 
the  mode  of  living  of  a  soldier,  to  a  certain  extent, 
should  follow  a  fixed  standard.  His  meals  should 
be  equally  distributed  through  the  day,  and  he 
should  never  be  put  to  work  without  having 
broken  his  fast,  however  light  the  meal  be.  If 
this  be  neglected  faintness  sometimes  ensues,  and 
exertion  fails  from  mere  craving  of  the  stomach. 
In  camp  soldiers  should  live  with  regularity,  and 
the  breakfast  and  dinner  hour  should  be  respected. 


SUGGESTIONS.  49 

It  is  on  the  march  that  circumstances  prevent  the 
carrying  out  of  rules. 

The  following  is  the  order  which  experience  has 
proved  to  be  most  useful  in  the  French  service. 
A  soldier  should  never  commence  a  march  without 
having  partaken  of  a  repast.  A  cup  of  hot  coffee 
with  bread  soaked  in  it  will  sustain  a  march  of 
some  duration.  A  little,  meat  would  be  an  im- 
provement, which  is  always  saved  by  the  pru- 
dent soldier  from  the  previous  day's  meal.  For 
night  marching,  an  alcoholic  drink  after  the  meal 
will  enable  him  to  undergo  much  more  fatigue. 
Preparatory  to  marching,  the  soldier  tills  his  can- 
teen with  good  water,  or  what  is  much  more  re- 
freshing, weak  coffee  or  tea.  The  start,  especially 
in  summer,  should  always  be  at  the  break  of  day. 
After  marching  three-fourths  of  an  hour,  the  col- 
umn stops  for  twenty  minutes.  In  resuming  the 
march,  a  halt  is  made  for  a  few  minutes  in  each 
hour.  In  crossing  a  ford,  the  men  take  off  their 
pantaloons,  keeping  on  their  shoes.  A  sentinel 
guards  any  fresh-water  spring  which  is  met  in  the 
march,  to  prevent  soldiers  from  gorging  them- 
selves—  a  very  wise  measure,  which  prevents 
much  sickness. 

Water  should  be  always  taken  in  reserve  and 
with  precaution.  When  taken  in  great  quanti- 
5 


50  SUGGESTIONS    TO    RELIEVE    THE 

ties   it   weakens  and  fatigues   the   organs   of  di- 
gestion, increases  perspiration   and   enervates  the 
entire    system.       It    is    particularly   injurious    to 
drink    rapidly    and    freely    when     heated    from 
exercise,  as  sudden   death  is  not  very  rare  from 
this  imprudence.       The    soldier  should  accustom 
himself,    when    thirsty,    to    drink   slowly   and   in 
small  mouthfuls,  keeping  the  water  in  the  mouth 
and  throat  as  long  as  possible.     The  cravings  of 
thirst  are  often  produced  by  a  parched  condition 
of  the    lining  membrane  of  the  mouth;    and  by 
rinsing  the  mouth  frequently,  thirst  can  be  allayed 
to  such  a  degree  that  but  little  water  will  be  re- 
quired,  whilst   much,  hurriedly   drunk,    will  not 
satisfy  the  urgent  call.     In  marching,  thirst  can, 
in  a  measure,  be  prevented  by  keeping  the  mouth 
closed,   and   in   speaking  as  seldom  as   possible; 
otherwise,  the  dry  air,  often  loaded  with  dust,  will 
parch  the  lining  membrane  of  the  mouth — a  very 
distressing  sensation  when  it  cannot  be  relieved 
by  drinking.     When,  during  a  march  or  halt,  the 
fatigued  and  thirsty  soldier  finds  water,   instead 
of  rushing  to  it  at  once,  he  should  first  try  and  . 
repose    himself    before    drinking;    then,    having 
washed  out  his  mouth  several  times,  drink  slowly 
so  as  to  make  the  smallest  possible  quantitj^  of 
water  supply  his  necessities.     Washing  the  face 


ANNOYANCES    OF    THE    MARCH.  51 

slackens  thirst.  As  good  water  is  not  always  to 
be  obtained  on  a  march,  a  soldier  should  never 
lose  an  opportunity  to  fill  his  canteen  with  fresh 
water.  If  the  canteens  be  covered  with  a  light 
colored  woollen  cover,  the  water  will  keep  cooler 
than  in  bright  tin,  which  absorbs  heat  more  rap- 
idly,  and  extends  it  to  the  contents  of  the  canteen. 
When  troops  have  had  an  early  start,  they  should 
bivouac  about  ten  o'clock  in  the  morning,  and  lie 
over  for  the  heat  of  the  day,  as  soldiers  on  march 
should,  if  possible,  be  protected  from  the  midday 
sun.  Here  they  will  have  time  to  cook  their  mid- 
day meal,  wash  their  clothes  and  refresh  them- 
selves from  their  fatigue.  This  meal  consists  of 
coffee  and  bread,  with  meat  cooked  and  saved 
from  the  preceding  day's  repast,  The  want  of 
this  precaution,  which  old  soldiers  adopt,  is  se- 
verely felt  by  recruits.  The  experienced  soldier 
never  forgets  to  keep  in  reserve  a  certain  propor- 
tion of  meat  or  other  food,  against  a  deficient  dis- 
tribution or  the  want  of  time  for  properly  prepar- 
ing it,  The  meal  should  be  taken  in  the  shade, 
under  some  protection  from  the  sun.  A  few 
branches,  properly  arranged,  will  form  a  comfort- 
able shelter.  The  main  meal  of  meat,  vegetables, 
etc.,  should  be  taken  after  the  evening  halt,  at  the 
end  of  the  dav's  march.     The  officer  in  charsre  of 


0"J  CAMP. 

the  troops  'should  always  know  the  road  over 
which  he  is  to  travel  the  next  day,  and  when  he  is 
compelled  to  bivouac  in  places  where  the  prospect 
for  getting  wood  is  bad,  each  soldier  should  carry 
on  his  knapsack  a  small  quantity  to  cook  his  mid- 
day meal  with. 

In  the  evening  halt,  the  site  selected  for  the 
camp,  when  possible,  should  be  on  rising  ground, 
free  from  low  places,  and  in  proximity  with  water 
and  wood.  These  rules  become  of  special  impor- 
tance in  establishing  a  camp  for  even  a  few  days 
stay.  It  is  prudent  to  avoid  the  immediate  vicinity 
of  swamps  and  rivers ;  the  emanations  from  such 
are  noxious,  often  pestilential,  but  fortunately  do 
not  extend  to  a  great  distance.  Interposing  a 
piece  of  rising  ground  or  woods  is,  as  a  general 
rule,  sufficient  to  turn  or  break  currents  from 
these  low  places,  and  protect  from  their  hurtful 
influence.  It  would  be  preferable  to  camp  in  the 
direction  of  the  regular  wind  currents,  so  that 
emanations  may  be  wafted  in  the  contrary  direc- 
tion. 

When  the  halt  is  only  for  the  night,  and  the 
camp  wagons  with  the  tents  have  not  come  up, 
the  men  bivouac  under  the  clear  sky,  or  seek 
shelter  under  a  few  branches,  with  which  they 
form  a  rough  shed  that  will  protect  them  from 


CAMP.  53 

dew.  If  possible,  dry  grass  or  leaves  form  their 
bed,  and,  lying  in  their  great  coats  and  upon  their 
india-rubber  cloth,  they  can  enjoy  peaceful  slum- 
ber. If  there  is  no  cover  for  the  men,  then  they 
build  fires,  and  sleep  around  these  as  so  many 
radii  of  a  circle,  the  feet  of  the  sleepers  being 
nearest  to  the  fire.  Singular  to  say,  this  kind  of 
rough  life  does  not  bring  with  it  disease,  as  one 
would  suppose.  If  the  men  are  warmly  clad,  they 
enjoy  more  health  when  bivouacked  than  when  in 
camp. 

The  site  of  a  permanent  camp  should  be  dry, 
with  good  drainage,  the  dryness  of  the  soil  being 
tested  by  digging,  to  see  that  a  stratum  of  water 
does  not  immediately  underlie  the  crust.  In  cold, 
damp  countries,  the  material  for  tents  should  be 
close,  and,  as  nearly  as  possible,  water-proof;  and 
when  pitched,  a  good  ditch  should  be  dug  around 
it,  with  the  earth  banked  up  against  the  tent  to 
keep  out  the  cold  and  rain,  and  also  to  prevent 
draughts.  Communicating  ditches  should  be  pro- 
vided to  facilitate  drainage.  The  circular  tent 
offers  the  best  protection  against  the  wind,  is  least 
liable  to  be  blown  down,  and  is  most  useful  for 
winter.  The  light  shelter  tent  of  the  French 
troops,  as  introduced  by  Marshal  Bugeaud,  will  be 
found  most  convenient  for  the  summer  months 


54  CAMP. 

for  an  army  in  the  field.  The  tent  is  made  of  the 
knapsack  of  the  soldier,  which,  instead  of  being 
sewed  up,  has  its  sides  buttoned  together.  When 
unbuttoned,  it  is  a  square  piece  of  cloth.  When 
two  or  four  sacks  thus  spread  open  are  buttoned 
together,  and  the  centre  supported  by  two  sticks 
three  feet  long,  and  the  angles  staked  to  the 
ground  by  small  camp  pins,  the  two  or  four 
persons  to  whom  the  sacks  belong,  by  thus 
joining  property,  have  a  tent  that  will  keep 
them  from  exposure  to  the  sun,  and  also  protect 
them  from  rain  or  dew.  This  tent  is  not  more 
than  three  feet  high  at  its  angle.  In  hot  and 
dry  weather,  instead  of  pinning  the  two  ends 
to  the  ground,  one  of  them  can  be  hung  hori- 
zontally to  branches  of  trees,  leaving  one  side 
open  for  thorough  ventilation,  whilst  the  hori- 
zontal portion  protects  the  sleeper  from  undue 
exposure.  The  size  of  this  tent  can  be  increased 
to  any  extent  by  joining  stock,  as  all  such  sacks 
are  of  the  same  size,  with  buttons  and  button 
holes  arranged  equidistant,  By  employing  this 
excellent  suggestion,  you  avoid  loading  the  shoul- 
ders of  the  soldier,  or  transporting  tents  for  the 
army,  which  is  often  impracticable.  In  a  few 
minutes  after  a  halt  tents  are  pitched,  and  the 
camp  has  assumed  its  regular  appearance,  with- 


BED    OF    SOLDIER.  55 

out  waiting  for  the  baggage  train.  These  tents, 
so  convenient  and  always  at  hand,  were  of  great 
service  in  the  Crimea,  but  particularly  in  Italy 
in  1859,  where  they  were  the  sole  protection  for 
the 'troops. 

The  soldier's  bed  should  never  be  directly  upon 
the  ground  ;  but  if  beds  cannot  be  obtained, 
branches  or  dried  leaves  or  straw  should  be  used, 
upon  which  the  blankets  are  spread.  This  an- 
swers the  double  purpose  of  keeping  the  body 
from  the  damp  ground  and  also  elevating  it  into  a 
layer  of  purer  air.  When  the  tent  is  filled,  as  is 
usually  the  case,  the  exhaled  air.  loaded  with  car- 
bonic acid  and  other  impurities,  settles  to  the 
ground,  which  persons  sleeping  upon  the  soil 
would  be  continually  inhaling,  to  their  injury. 
The  soldier's  bed  should  be  always  dry.  All 
moist,  decomposing  materials,  as  green  grass  or 
leaves,  are  more  injurious  than  sleeping  upon  the 
soil,  owing  to  the  gases  escaping  from  their  de- 
composition. True  economy  would  dictate  a 
painted  cloth  for  the  floor  of  the  tent,  which  is 
useful  in  preventing  the  exhalation  of  moisture 
from  the  earth's  surface,  is  convenient,  always 
ready  and  less  expensive  than  straw.  It  can  be 
cleaned  every  day  with  little  trouble,  without  cost, 
and  requires  to  be  freshly  painted  only  once  a 


58 


BED    OF    SOLDIER. 


with  three  or  four  inches  of  earth  or  a  sufficient 
layer  to  prevent  any  smell  arising  from  the  day's 
deposit;  and  when  the  trench  is  two-thirds  full  it 
should  be  closed  and  another  of  similar  dimensions 
opened.  Where  proximity  to  the  water  permits, 
these  privies  should  be  established  over  the  water. 
This  will  remove  a  great  and  common  source  of 
infection,  which  is  very  difficult  to  counteract. 

In  permanent  camps,  dead  animals,  horse  dung, 
and  all  animal  refuse,  should  also  be  buried,  other- 
wise the  stench  from  them  would  be  very  injurious 
to  the  health  of  the  troops.  But  as,  notwithstand- 
ing the  utmost  care,  in  the  most  salubrious  situa- 
tions, diseases  will  in  time  show  themselves — from 
the  inevitable  accumulation  of  poisonous  materials, 
resulting  from  the  growing  infection  of  the  soil, 
with  its  poisonous  emanations,  from  the  prolonged 
sojourn  of  a  large  number  of  men  and  animals — 
the  camp,  unless  occupying  a  position  of  marked 
military  importance,  should  be  changed  for  a  new 
situation  at  some  convenient  distance.  For  a  per- 
manent camp,  board  huts  are  much  more  com- 
fortable and  healthy  for  troops,  whilst  for  transient 
halts  a  shelter  composed  of  branches  is  much 
more  desirable  than  tents.  Troops  bivouacked  are 
always  more  healthy  than  those  regularly  under 
shelter.     It  is  well  known  that  irregular  troops, 


AMUSEMENTS.  59 

which  act  iii  the  advance  line  of  armies,  and  which 
have  no  other  shelter  from  weather  than  a  tree, 
rarely  experience  sickness,  never  at  least  the  sick- 
ness which  proceeds  from  contagion,  an  evil  con- 
tingent to  camps.  One  great  advantage  of  using 
huts  is,  that  they  are  left  behind  with  the  infec- 
tious air  which  might  have  been  generated  within 
them,  whilst  the  same  contagion  is  often  trans- 
ported with  the  tents. 

To  enliven  and  relieve  the  toil  and  tedium 
of  camp  life,  amusements  are  a  very  neces- 
sary portion  of  the  day's  duties ;  and  it  is  found 
that  lively  music  from  the  military  bands  every 
afternoon  will  elate  the  men  and  remove  monoto- 
ny. In  the  summer  of  1859,  during  the  Italian 
campaign,  I  was  at  Milan  when  a  large  body  of 
French  troops,  returning  from  the  blood}7  field 
of  Solferino,  arrived.  In  a  few  minutes  their 
shelter  tents  were  pitched  under  the  shade  of 
the  trees  on  the  broad  Boulevard  which  sur- 
rounds the  city,  and  the  soldiers  were  allowed 
to  follow  the  bent  of  their  own  inclination.  Card- 
playing,  dominoes,  fortune-telling,  wrestling,  and 
dancing  to  the  discordant  tunes  of  a  hand  organ, 
or  the  sharp  notes  of  an  accordeon,  appeared  to 
be  the  order  of  the  day. 

Pets   in   various   forms   were  commonly  found 


HO  AMUSEMENTS, 

among  the  troops,  and  these  were  guarded 
with  scrupulous  care.  Many  appeared  to  be 
adopted  by  the  regiment  as  comrades,  who 
have  been  associated  together  through  many  a 
hard-fought  field  and  toilsome  march.  In  the 
military  hospitals  of  Milan — which  were  filled  with 
the  wounded,  from  its  very  near  proximity  to  the 
battle  field  and  railroad  facilities  for  transporta- 
tion— it  was  not  unusual  to  see  a  soldier  nearly 
exhausted  from  the  tedious  dressing  of  a  frightful 
wound,  when  he  had  passed  from  the  hands  of  the 
surgeon,  take  from  his  bosom  a  little  sparrow,  and 
from  the  cheerful  chirp  of  this  little  bird  appear 
to  derive  much  consolation. 

Not  the  least  attractive  incident  connected 
with  the  triumphal  march  of  Napoleon's  Italian 
army  through  Paris,  in  August,  1859,  was  the 
pets  accompanying  these  brave  heroes.  Here 
would  be  seen  a  goat,  evidently  proud  of  its 
position,  marching  with  military  step  at  the 
head  of  a  column  of  ferocious  Zouaves ;  going 
through  the  halt  and  advance  by  word  of  com- 
mand, looking  neither  to  the  right  or  left,  as 
if  !v  success  of  the  day  depended  upon  its  mili- 
tary deportment.  Here,  a  regimental  dog  would 
show  the  pleasure  with  which  he  participated 
in  this  great  occasion,  whilst  the  caresses  of  the 


AMUSEMENTS.  61 

company  and  the  pleasant  faces  with  which  his 
presence  would  always  be  recognized,  show  the 
appreciation  of  his  companionship.  These  little 
incidents  are  introduced  to  show  the  lone'ins:  of 
all  men  for  objects  of  affection,  and  also  how  many 
a  tedious  and  otherwise  unbearable  hour  in  camp 
life  is  pleasantly  spent  in  fostering  those  fine  feel- 
ings of  the  human  heart,  which  keep  soldiers 
accustomed  to  blood  from  becoming  degraded 
and  brutal. 


CHAPTER    III. 

Hospitals,  Regimental  and  General — Hospital  Tents, 
with  Equipment — Number  of  Attendants  allowed — 
Care  necessary  in  preventing  Infection — Value  of 
Fumigation — Female  Attendants — Hospital  Diet. 

The  accommodations  for  the  sick  form  a  very 
important  department  in  the  economy  of  an 
army,  and,  as  a  rule,  are  never  sufficiently  am- 
ple. With  every  body  of  troops,  in  the  field, 
there  are  two  kinds  of  hospitals — the  regimental 
and  the  general.  With  regular  armies,  there 
should  always  be  a  third — the  convalescent  hos- 
pital— situated  in  some  salubrious,  rural  location, 
where  convalescents,  by  inhaling  pure  air,  and 
enjoying  the  pleasures  of  country  life,  can  rapidly 
rebuild  their  shattered  constitutions.  The  regi- 
mental hospital  is  usually  under  tents,  when  in 
the  field,  if  a  suitable  building  in  the  imme- 
diate vicinity  of  the  encampment  cannot  be  ob- 
tained. 

The  tents  used  as  hospitals  in  the  Confederate 
service  are  fourteen  feet   in   length,    fifteen   feet 


HOSPITAL    TENTS. 


63 


wide,  and  eleven  feet  high  in  the  centre,  with 
a  wall  four-and-a-half  feet,  and  a  "fly''  of  appro- 
priate size.  The  ridge  pole  is  made  in  two  sec- 
tions, measuring  fourteen  feet  when  joined.  On 
one  end  of  the  tent  is  a  lapel,  so  as  to  admit  of 
two  or  more  tents  heing  joined  or  thrown  into 
one,  with  a  continuous  covering  or  roof;'  such  a 
tent  accommodates,  comfortably,  from  eight  to 
ten  patients.  The  following  is  the  allowance  of 
tents  for  the  sick,  their  attendants  and  hospital 
supplies — being  accommodation  for  ten  per  cent, 
of  the  command: 


COMMANDS. 

HOSPITAL  TENTS. 

SIBLEY  TENTS. 

COMMON  TEXTS. 

For  three  companies. . . 
For  five  companies. . . . 
For  seven  companies... 

1 

2 
2 

3 

1 
1 
1 
1 

1 

1 

1 

1 
1 
1 

Only  those  cases  which  promise  to  be  transient 
indispositions  or  acute  diseases  are  retained  for 
treatment  in  the  regimental  hospitals.  They  are 
temporary  structures,  to  be  moved  with  the  army 
and  to  be  broken  up  at  an  hour's  notice.  They 
should  never,  therefore,  be  encumbered  with 
chronic  cases,  nor  should  they  ever  be  permitted 
to  be  crowded.  As  soon  as  a  case  threatens  to 
remain  longer  than  eight  or  ten  days  in  hospital,  it 


04  HOSPITAL    TENTS. 

should  be  transferred  to  the  general  hospital  for 
treatment. 

To  ensure  a  comfortable  abode  for  the  sick, 
the  site  of  the  regimental  hospital  should  be 
selected  with  much  care  —  the  driest  spot  in 
the  camp  should  be  chosen,  and  the  tent  well 
ditched"  to  give  thorough  drainage.  The  floor 
of  the  tent  should  be  carpeted  with  oiled  floor- 
cloth or  painted  canvas,  which  will  protect  the- 
sick  from  the  emanations  from  the  soil,  and 
will  prevent  the  soil  from  imbibing  animal  efflu- 
via. It  also  keeps  out  all  moisture,  which  is 
so  deleterious  to  those  lying  upon  the  ground. 
This  painted  cloth  strictly  belongs  to  the  hospital 
tent,  and,  as  an  essential  part,  should  never  be 
overlooked.  A  certain  number  of  bed-sacks  also 
belong  to  the  hospital.  When  these  are  filled 
with  straw,  they  make  a  much  more  comfortable 
bed  than  straw  thrown  in  heaps,  which  is  the  com- 
mon mode  of  treating  the  sick  in  the  field.  There 
is  much  comfort  in  appearances,  and  these  beds 
add  much  to  the  neatness  as  well  as  cleanliness 
of  the  tent.  The  beds  are  arranged  pn  either  side 
of  the  tent,  with  the  heads  turned  toward  the  wall. 
Could  the  beds  be  elevated  upon  boards  for  six  or 
twelve  inches,  they  would  place  the  sick  in  a  purer 
atmosphere  than  when   lying  on  the  floor,  where 


HOSPITAL    TENTS.  65 

the  heavy  deleterious  gases  of  expiration  collect. 
In  good  weather  ventilation  of  these  tents  should 
always  be  insisted  upon.  When  the  painted  floor- 
cloth is  not  at  hand  the  earthen  floor  should 
be  well  rammed,  and  should  be  daily  watered  with 
a  milky  lime  water,  as  a  purifier. 

The  straw  should  be  changed  as  often  as  pos- 
sible, even  twice  a  week,  if  it  can  be  procured  ; 
whilst,  if  the  patient  can  get  up,  the  bed  should 
be  well  beaten  and  thoroughly  aired  daily.  Per- 
sonal cleanliness  of  the  patient  is  as  important  as  that 
of  the  tent.  Ablutions  must  be  freely  used,  and 
under-clothing  frequently  changed.  Whenever 
the  patients  permit,  the  tent  should  be  moved 
once  a  week,  if  it  be  only  a  few  yards  from  its 
former  position,  so  as  to  enclose  a  fresh  piece  of 
soil  not  contaminated  with  animal  exhalations. 
This  change  of  location  is  particularly  required 
whenever  any  of  the  low  grades  of  contagious 
diseases  appear  within  its  walls,  or  cases  under 
treatment  take  on  an  asthenic  character. 

The  hospital  is  allowed  a  certain  number  of 
attendants  to  attend  to  the  commissary  and 
medical  duties  of  the  establishment.  Each  com- 
pany has  one  steward,  one  nurse,  and  one 
cook;  for  each  additional  company  one  nurse 
is  added;  and,  for  commands  of  over  five  corii- 
G 


66  HOSPITAL    TENTS. 

panies,  one  additional  cook,  The  surgeon  is 
general  superintendent  of  the  hospital.  Under  his 
direction  the  steward  takes  care  of  the  hospital 
stores  and  supplies,  and  sees  that  the  nurses  and 
cooks  perform  properly  their  respective  duties. 
Often,  he  acts  as  medical  dispenser  and  apothe- 
cary to  the  regimental  hospital.  If  intelligent, 
he  can  readily  be  instructed  in  the  preparation 
of  prescriptions  for  the  sick,  and  relieve  the  sur- 
geon of  this  trouble. 

Not  the  least  important  personage  in  the  hos- 
pital organization  is  the  sentinel,  who  guards  the 
door,  and  sees  that  neither  ingress  nor  egress  is 
permitted  except  upon  orders  from  the  surgeon. 
It  is  only  in  this  way  that  patients  can  be  pre- 
vented from  committing  imprudences  which  may 
cost  them  their  lives.  This  guard  should  be  con- 
stantly furnished  to  the  hospital,  and  the  surgeon 
is  to  signify  to  the  commanding  officer  of  the 
regiment  the  particular  orders  which  he  wisbes 
to  be  given  to  the  non-commissioned  officer  com- 
manding it  and  to  the  sentries. 

Those  treated  in  a  tent  hospital  always  conva- 
lesce much  more  rapidly  than  those  collected 
together  in  a  large  hospital  building,  where,  in 
proportion  to  the  magnitude  of  the  establishment 
and  number  of  patients,  we  find  the  convalescence 


THE    GENERAL    HOSPITAL.  07 

of  the  sick  prolonged,  the  number  of  deaths 
increased,  and  the  development  of  the  germs  of 
contagious  diseases.  In  concentrating  a  number 
of  sick  under  one  roof,  the  laws  of  hygiene  will 
be  violated — it  cannot  be  avoided.  Yet,  from  the 
very  transient  nature  of  regimental  hospitals, 
more  permanent  institutions  for  the  sick  must  be 
established. 

The  general  Jiospital,  for  the  use  of  a  division 
of  the  army,  is  usually  located  in  some  town  or 
city  contiguous  to  the  army ;  or,  should  these 
be  too  distant,  without  facilities  of  transporta- 
tion, some  buildings  are  taken  possession  of  near 
the  lines  and  converted  into  a  hospital.  The 
organization  of  this,  with  its  surgical  staff,  its 
steward,  ward-master  and  nurses,  is.  upon  a  much 
grander  scale.  Ordinarily,  the  following  hospital 
attendants  are  allowed :  A  steward,  a  ward-mas- 
ter, an  orderly  (taken  from  the  ranks)  to  act  as 
nurse  for  every  ten  sick,  a  matron  for  every  twenty, 
and  one  cook  to  every  thirty  patients.  Each  nurse 
is  made  responsible  for  cleaning  and  taking  care 
of  ten  beds,  with  the  floor  and  utensils  included 
in  the  space  occupied  by  the  ten  beds.  His  duty 
includes  bringing  to  the  ward  and  distributing  to 
the  patients  the  daily  rations,  and  also  the  medi- 


68  THE    GENERAL    HOSPITAL. 

cines  prescribed  at  the  visit.  The  cooks  and 
nurses  are  taken  from  the  ranks,  and  are  returned 
when  no  longer  required  in  the  hospital.  In  a 
general  hospital  there  is  always  a  dispensing  officer 
or  apothecary,  who  prepares  the  prescriptions  of 
the  surgeon  and  delivers  the  same  to  the  nurses 
upon  application  at  the  dispensary.  In  regimental 
hospitals  the  surgeon,  or  his  assistant,  when  pres- 
ent, performs  this  duty,  if  an  intelligent  steward 
has  not  been  instructed  by  the  surgeon  in  pre- 
paring medical  prescriptions.  In  a  large  general 
hospital  the  steward  represents  the  commissary 
department."  Whoever  attends  to  the  pharma- 
ceutical department  should  be  careful  to  keep 
all  poisonous  drugs  under  key,  so  that  no  acci- 
dent might  occur  to  the  inmates  of  the  hospital, 
whether  by  design  or  through  mistake. 

In  this  general  hospital  we  have  regular  wards, 
which  are  always  objectionable  from  the  number 
of  sick  crowded  into  these  compartments.  Every 
bed  for  a  patient  should  have  a  certain  number  of 
cubic  feet,  or,  as  height  does  not  compensate  for 
area,  as  all  the  dangerous  gases  stagnate  in  the 
lower  strata,  it  would  be  better  to  allow  each  pa- 
tient so  many  square  feet,  say  fifty  square  feet  for 
each  bed.  For  those  who  are  severely  wounded  or 
sick  with  typhus,  twice  this  area,  or  one  hundred 


PURIFICATION    OF    HOSPITALS.  69 

square  feet,  will  not  be  too  much  space,  if  it  be 
desirable  to  prevent  pysemia,  hospital  gangrene, 
erysipelas  and  other  fatal  complications  from  show- 
ing themselves.  Rooms,  with  less  than  ten  feet 
ceiling,  are  not  fit  accommodation  for  the  sick. 
With  the  constant  tendency  to  a  poisoning  of  the 
•atmosphere  from  imperfect  ventilation,  all  pre- 
cautions of  cleanliness  cannot  be  too  rigidly 
enforced. 

Such  a  general  hospital  should,  among  other 
things,  be  liberally  furnished  with  hospital  cloth- 
ing. In  European  general  military  hospitals  the 
patient  leaves  everything  behind  him  when  he 
enters  its  wards.  He  receives  a  bath  and  is 
dressed  up  in  the  hospital  clothes ;  his  own  are 
washed  and  stowed  away,  properly  labelled  by  the 
ward-master.  Should  he  be  suffering  under  any 
contagious  disease,  as  the  itch,  typhus  fever,  etc., 
his  clothing,  after  being  well  beaten  and  washed 
in  boiling  water,  are  fumigated  for  twenty-four 
hours  in  a  closed  chamber  or  tent  with  chlorine 
gas.  With  itch  patients,  sulphur  fumigations  are 
substituted  for  chlorine. 

When  any  low  form  of  disease  makes  its  ap- 
pearance in  a  ward,  it  would  be  better  could  it 
be  temporarily  abandoned.  Then,  let  it  undergo 
a  thorough    cleansing    and    whitewashing,    with 


70  PURIFICATION    OF    HOSPITALS, 

fumigations  of  chlorine.  Heating  the  air  con- 
tained within  the  closed  room  by  means  of 
stoves,  so  as  to  attain  a  high  temperature,  may 
destroy  the  fomites  causing  the  disease  and  ren- 
der the  ward  again  habitable.  This  course  should 
also  be  adopted  whenever  a  ward  has  been  occu- 
pied by  the  seriousby  injured,  with  extensively 
suppurating  wounds.  Should  any  one  enter,  at 
midnight,  a  ward  thus  inhabited,  the  insufferable 
smell,  and  the  apparent  weight  of  the  atmosphere, 
would  at  once  explain  the  danger  of  infective 
diseases  and  the  necessity  for  not  only  constant 
cleanliness  and  continued  ventilation,  but  also 
for  purifying  the  same  at  intervals.  Such  rooms, 
it  is  said,  should  be  thrown  out  of  use  for 
two  weeks  after  every  two  months  occupation. 
This  is  laid  down  as  an  important  hospital  regu- 
lation by  Stromyer,  in  his  Maxims  of  Military 
Surgery,  based  upon  experience  and  observa- 
tion during  the  Schleswig-Holstein  war.  Chem- 
ical disinfectants  were  not  found  useful  by  him 
when  the  rooms  were  occupied ;  the  rooms 
must  be  empty.  For  occupied  rooms,  draughts  of 
fresh  air  ore  the  only  good  disinfectants.  The  slight 
exposure  to  catarrhal  affections  is  nothing,  when 
compared  to  the  danger  of  introducing  infectious 
diseases,  by  permitting  a  foul  and  unrenewed  at- 


PURIFICATION    OF    HOSPITALS.  71 

mosphere  to  be  inhaled  by  the  wounded.  It  is 
owing  to  the  advantages  of  ventilation,  that  tents 
are  so  much  better  for  typhus  and  severely  wound- 
ed patients  than  wards.  Pure  air,  continually 
renewed,  is  essential  for  the  cure  of  typhus. 
Abundance  of  fresh  air  covers  a  multitude  of 
inconveniences.  In  the  Crimean  service,  the 
French  attached  great  importance  to  the  fumi- 
gation of  their  wards.  The  surgeons  of  their 
immense  military  hospitals  thought  that  they 
derived  decided  benefit  from  adopting  the  Turk- 
ish custom  of  fumigating  with  dried  sage,  which 
was  burnt  in  the  wards  three  times  a  day,  be- 
side the  use  of  chlorine  fumigations  morning 
and  evening. 

Baudens  states  that,  bj  using  chlorine  fumiga- 
tions at  6,  a.  M.,  and  at  7,  p.  m.,  the  dried  sage  at 
7J,  a.  m.,  1,  p.  m.  and  8|,  p.  m.,  he  succeeded  in 
preventing  as  well  as  stopping  infectious  disorders. 
A  saucer  of  chloride  of  lime  was  also  placed  under 
the  bed  of  each  typhus  patient.  It  is  a  question 
whether  these  fumigations  act  from  the  medi- 
cinal virtues  which  they  possess,  or  upon  hygienic 
principles.  The  European  nations  have  such  a 
dread  of  draughts,  that  a  door  or  window  is 
never  left  open.  We  would  judge  that  they  were 
intended  to  give  light,   and   not  air.     The   only 


<-S  PURIFICATION    OF    HOSPITALS. 

way  in  which  such  herb  fumigations  can  be  of 
use  is  to  make  the  atmosphere  so  disagreeable 
that  all  the  windows  must  be  thrown  open  to  get 
rid  of  it.  As  it  escapes  from  these  openings,  fresh 
air  equally  rushes  in  to  purify  the  room. 

This  difficulty  of  ventilation  through  the  win- 
dows, which  are  the  proper  media  for  it,  is  the 
common  subject  of  complaint  among  the  medical 
staff  of  hospitals.  Stromyer  had  to  enter  into  a 
regular  compact  with  his  German  patients.  He 
would  only  allow  them  to  smoke  provided  they 
would  keep  the  windows  open,  using  this  subter- 
fuge to  ventilate  the  wards.  A  celebrated  English 
medical  lecturer  placed  the  value  of  fumigations 
in  their  true  light  when  he  said,  "fumigations  are 
of  essential  importance ;  they  make  such  an  abomina- 
ble smell  that  they  compel  you  to  open  the  windows. " 
When  these  means  are  used,  without  affording 
the  impure  air  means  of  escape  the}7  only  act  as 
masks,  disguising,  by  their  stronger  odors,  the 
offensive  and  injurious  exhalations  from  the  sick. 
It  quiets  the  anxieties  of  the  nurse  without  in  any 
way  benefiting  the  patient.  It  must  never  be  for- 
gotten that  many  symptoms  which  are  said  to  be- 
long to  a  disease,  depend  upon  the  circumstances 
under  which  it  is  treated,,  and  many  of  these  can 
with  truth  be  accredited  to  bad  ventilation ;  hence 


PURIFICATION    OF    HOSPITALS.  78 

the  different  phases  which  diseases  assume  when 
treated  in  hospitals  or  in  private  practice.  If  such 
causes  will  produce  disease  (a  fact  with  which 
every  one  is  familiar),  how  much  more  likely 
are  they  to  modify  those  already  existing.  Every 
physician  of  experience  and  observation  has  seen 
serious  cases  of  fever,  threatening  a  fatal  issue, 
commence  to  improve  from  the  moment  that 
the  patient  was  changed  from  the  room  in  which 
he  had  long  been  lying,  with  its  closed  windows 
and  musty  smell,  to  a  light,  cheerful,  well-venti- 
lated chamber.  This  is  always  attributed  to 
change  of  scene,  whilst  the  true  cause,  change  of 
air,  is  overlooked. 

Typhus  cases  particularly,  should,  if  possible, 
be  isolated  in  tents,  and  ample  room  be  given  to 
each.  Over-crowding  is  certain  to  produce  such  a 
condition  of  the  atmosphere  as  to  heighten  the 
mortality.  It  also  becomes  imperative  upon  those 
taking  care  of  such  infectious  diseases  to  breathe 
the  air  as  little  as  they  can:  live  out  of  the  room 
or  tent  as  much  as  possible,  compatible  with 
the  proper  attendance  upon  the  sick,  and  take 
exercise  freely  in  the  open  air.  The  medical 
attendants  upon  typhus  hospitals,  or  in  such  as 
are  infested  with  pyaemia,  gangrene,  etc.,  should 
frequently   change   places   with    those   in    charge 


74  PURIFICATION    OF    HOSPITALS. 

of  more  healthy  institutions;  otherwise  the  per- 
manent medical  attendant,  inhaling  daily  this 
poisoned  atmosphere,  will  be  sacrificed  to  an 
absence  of  a  regular  interchange  of  stations  and 
duties. 

In  the  best  regulated  hospitals  each  typhus  case 
has  two  beds.  Every  twelve  hours  he  is  changed, 
and  the  bedding  upon  which  he  has  been  lying 
fumigated  and  well  aired.  The  bed  and  body 
linen  of  such  is  also  changed  daily.  As  typhus  is 
known  by  its  infecting  nature  and  its  easy  trans- 
mission, the  hospital  wards  cannot  be  protected 
by  too  many  hygienic  regulations.  When  a  hos- 
pital has  become  infected  with  typhus,  pypemia  or 
hospital  gangrene,  it  is  best  to  close  it  and  turn 
out  all  patients.  It  would  be  much  safer  for  the 
sick  and  wounded  to  stay  in  the  streets  or  lie  in 
the  fields,  than  be  sent  to  such  an  infected  estab- 
lishment. His  permit  for  admission  is  his  death- 
warrant;  whilst  combating  the  elements  would 
give  him  at  least  a  chance  of  coming  off  conqueror. 
Any  temporary,  well-ventilated  structure — a  hut 
rudely  made  of  rough  boards — would  be  much 
healthier  than  gorgeous  palaces  with  gilded  cham- 
bers, in  which  death  sits  in  state  to  receive  its 
victims. 

In   general   hospitals,    the   blessings    of    a   wo- 


PURIFICATION    OF    HOSPITALS.  I'O 

man's  care,  her  ever-watchful  eye  and  soothing 
words,  her  gentleness  and  patience,  have  recently 
been  felt.  Florence  Nightingale,  when  she  made 
her  disinterested  offer  to  nurse  the  sick  in  the 
Crimea,  could  have  little  foreseen  the  new  era 
dawning  for  suffering  humanity,  and  the  benefits 
which  she  was  bestowing  upon  future  genera- 
tions. It  is  woman's  peculiar  prerogative,  as  it 
is  her  earthly  mission,  to  give  comfort  to  those 
in  distress  ;  and  when  the  English  adopted  the 
custom  long  prevalent  in  France,  to  allow  fe- 
male nurses  to  minister  to  the  wants  of  those 
suffering  in  military  hospitals,  the  wounded  felt 
that  half  their  solicitude  was  removed.  Now,  a 
sister's  care  will  bathe  the  sufferer's  aching  head 
or  offer  him  the  cooling  draught  to  allay  his 
parched  thirst ;  will  sympathize  with  his  pains 
and  give  sweet  consolation  to  his  dejected  spirit; 
and  by  removing  that  overpowering  weight  of 
loneliness,  by  which  the  sick  in  a  foreign  land  far 
from  home  and  friends  are  oppressed,  will  pave 
the  road  to  speedy  convalescence.  A  cheerful 
look,  a  kind  word,  a  pleasant  smile  from  one  of 
these  self-denying  sisters,  has  sent  many  a  thrill 
of  pleasure  through  a  stricken  soul.  The  sur- 
geon sees,  at  his  next  visit,  the  fruit  of  this  pleas- 
antly-administered draught,  which  perhaps  he  at- 
tributes to  his  own  nauseous  drugs. 


76  PURIFICATION    OF    HOSPITALS. 

The  experience  of  the  Crimean  hospitals,  recog- 
nizing the  vast  amount  of  good  which  the  female 
nurses  accomplished,  and  the  incalculable  service 
which  they  are  capable  of  performing,  when  judi- 
ciously selected  and  properly  organized,  is  a  suffi- 
cient reason  why  they  should  be  attached  to  every 
hospital,  and  especially  in  times  of  war,  when  their 
many  and  peculiar  services  cannot  be  dispensed 
with.  To  the  surgeon,  a  good,  kind,  reliable  nurse 
constitutes  more  than  half  the  treatment  of  the 
sick.  It  is  with  the  most  serious  cases  that 
their  advantages  in  nursing  are  best  displayed. 
McLeod,  who  studied  carefully  woman's  services 
in  the  Crimean  hospitals,  says:  "A  woman's 
services  in  a  hospital  are  invaluable  if  they  were 
of  no  further  use  than  to  attend  to  the  cooking 
and  the  linen  departments;  to  supply  'extras' 
in  the  way  of  little  comforts  to  the  worst  cases ; 
to  see  that  the  medicines  and  wine  ordered  are 
administered  at  the  appointed  periods,  and  to 
prepare  and  provide  suitable  drinks.  As  to  the 
employment  of  'ladies,'  I  think  they  are  alto- 
gether out  of  place  in  military  hospitals,  except 
as  superintendents.  As  heads  of  departments, 
as  organizers,  as  overlookers,  '  officers '  of  the 
female  corps,  if  you  will,  they  cannot  be  dis- 
pensed  with ;    but  for  inferior   posts,  strong,  ac- 


DIET    TN    HOSPITALS.  77 

tive,  respectable  paid  nurses,  who  have  under- 
gone a  preliminary  training  in  civil  hospitals, 
should  alone  be  employed.  In  the  camp  hospitals, 
which,  with  an  army  in  the  field,  are  merely  the 
temporary  resting-places  of  the  sick,  men  should 
alone  be  employed  as  nurses  ;  but  in  the  more 
fixed  hospitals  in  the  rear,  the  lady  superinten- 
dents and  under-nurses  should  in  my  opinion 
always  be  added  to  the  regular  staff.  Their  atten- 
tion should  be  limited  to  the  bad  cases,  and  they 
should  have  the  entire  control  of  the  linen,  medi- 
cal comforts,  and  cooking. 

"  All  cleaning  should  be  done  by  men.  There 
should  be  a  lady  superintendent  over  each  divis- 
ion of  the  hospital,  responsible  to  the  surgeon  as 
well  as  to  her  own  lady  chief.  Then  there  should 
be  a  store  of  '  extras '  under  her  charge,  distribu- 
table on  recprisition  from  the  medical  attendant, 
and  which  depot  should  be  filled  up  to  a  certain 
quantity  weekly,  the  sister  being  held  accountable 
for  the  contents.  "Wine  and  all  extras  should  pass 
through  her  hands.  She  should  be  responsible  for 
the  due  performance,  by  her  female  subordinates, 
of  their  duties,  and  have  a  right  to  interfere  with 
the  ward-master,  if  the  cleaning,  etc.,  were  not 
properly  attended  to  by  his  male  corps." 

The   dieting   of  patients   in   a   hospital   is  always 


78  DIET    IN    HOSPITALS. 

a  matter  of  considerable  moment,  and  one  which 
requires  much  attention.  The  surgeon  has  dis- 
cretionary powers  to  order  any  extras  which  the 
patients  may  need  and  which  the  issue  of  rations 
does  not  include.  To  he  enabled  to  supply  these 
extra  articles  at  the  time  when  they  are  wanted, 
and  not  depend  upon  the  doubts  and  uncertainties 
of  the  regular  form  through  which  all  such  orders 
now  pass — a  kind  of  circumlocution  office,  whore, 
in  time,  the  articles  may  be  forthcoming — the 
medical  director  should  be  supplied  with  funds, 
for  the  judicious  outlay  of  which  he  becomes  per- 
sonally responsible.  From  this  fund  the  wants  of 
the  patients  can  be  supplied  without  delay. 

For  the  very  sick,  the  dietary  orders  being  indi- 
vidual, no  difficulty  exists  in  prescribing  for  them. 
It  is  for  those  drawing  ordinary  fare,  and  who 
require  to  be  guided  by  some  fixed  rule,  that  diet 
tables  are  found  so  useful  in  diminishing  the 
daily  routine  duties  of  the  surgeon.  This  diet 
list  is  carefully  compiled  by  the  medical  directors 
of  the  hospital,  and  contains  those  articles  of  diet 
which  would  be  best  suited  to  the  many.  As 
this  is  a  sine  qua  nan  in  a  hospital,  and  gives 
much  trouble  in  its  preparation,  I  have  here  in- 
troduced, as  a   guide,   a   diet  table,  which  might 


DIET    IN    HOSPITALS. 


79 


be  useful   as   a   basis    in    preparing   one   for   indi- 
vidual hospital  service. 

A  Scheme  of  Diet  for  Patients  in  the  Military  Hospital. 


FULL   DIET. 


Bread, 1     lb. 


Beef  or  Mutton,.  .1 
Potatoes,  or*)    ...1    lb, 
Beans,  ur. .  >   . . . 4     oz. 

Rice, J    . .  .4    oz. 

Veget'es  for  soup,  4    oz. 

Salt 1    oz. 

Tea,  or  ] "j  oz. 

Coffee,  J 1     oz. 

Sugar, 2 

Milk  for  tea, 4 

Molasses, 1 

Corn  Meal, 1 

Soup, 1 


HALF    DIET. 


Bread, £  lb. 

Tea, 4  oz. 

Sugar, 2    oz. 

Milk  for  tea,  ...4    oz. 

Corn  Meal, 1    lb. 

Milk 1     pt. 


Bread, 1    lb. 

Beef  or  Mutton,. .   *  lb. 

Potatoes,  or")    ...1     lb. 

Beans,  or. .  >  . .  .4    oz. 

Rice, j    . .  .4    oz. 

Veget'es  for  soup,  4    oz. 

Salt 1     oz. 

Tea, i  oz. 

Sugar 2    oz. 

oz.  |  Milk  for  tea, 4    oz. 

oz.  Molasses, 1     oz. 

oz.jCorn  Meal, 1     lb. 

lb.  [  Soup, i  pt. 

l't 

Veal,  Fowls,  or  Bacon — such  quantities,  in  lieu  of  beef  and  mutton 
as  the  medical  officer  may  prescribe. 

Wine,  Whiskey,  Porter  or  Ale,  at  the  surgeon's  discretion. 


Two  drachms  of  tea  or  four  of  coffee,  with  one 
ounce  of  sugar  and  one-eighth  pint  of  milk,  to  be 
allowed  to  each  patient  for  one  pint  of  tea  or 
coffee  morning  and  evening. 

The  beef  or  mutton  for  full  or  half  diet  is  to  be 
made  into  soup,  with  vegetables,  and  one  pint  of 
the  soup  given  to  each  patient,  with  his  propor- 
tion of  the  boiled  meat.  The  vegetables,  as  rice, 
potatoes  or  beans,  are  frequently  changed  to  give 
variety  to  the  meal. 


80 


DIET    IN    HOSPITALS. 


The  diet  would  be  distributed  in  the  following 
order : 


Breakfast 


Dinner  - 


Supper. 


Bread, J  lb. 

Tea  or  coffee, .  I     pt. 
Hominy  &  molasses 

Beef  or  mut'n,  I    lb. 
.1    pt. 


;oup. 


Bread i  lb. 

Beaus,  pot'es  or  rice 

Bread, J  lb. 

Tea  or  coffee, .  1     pt. 


Bread, £  lb. ;  Bread,    i  lb. 

Tea, 1     pt.  Tea,  ..1    pt. 

Hominy  &  molasses   Gruel,    i  pt. 


Beef  or  mut'n,    +  lb.    

Soup 1    pt.  Gruel.  I 

Bread, J  lb.  Milk,..l 

Beans,  pot'es  or  rice    


Bread, i  lb. 

Tea, 1     pt. 


Bread,  J  lb. 
Tea,  ..1  pt. 
Gruel,    i  pt. 


The  attending  surgeon  adds  what  he  wishes  to 
the  above  diet,  to  suit  any  individual  case  in  the 
hospital. 


CHAPTER    IV. 

Medical  Service  of  the  Army — The  means  of  trans- 
porting the  'wounded — Medical  and  Surgical  Staff  of 
Armies — The  Medical  organization  in  the  Prussian 
service — Sanitary  Corps,  or  litter  carriers  for  trans- 
-  porting  the  wounded  from,  the  field — Duties  of  the 
Regimental  Surgeons  and  Assistants  in  camv  and* 
on  the  battle  field — Preparations  needed  on  the  eve 
of  a  battle — Positions  occupied  by  the  Medical  Staff 
during  the  fight. 

The  transportation  of  the  sick  and  wounded  of 
an  army  is  always  a  matter  of  difficulty,  and  is  not 
uncommonly  the  indirect  cause  of  an  increased 
mortality.  The  injury  inflicted  upon  a  wounded 
man  by  a  transportation  of  even  a  few  hours,  over 
bad  roads,  and  in  unsuitable  vehicles,  is  incalcu- 
lable. Wounds  which  had  been  doing  well  prior 
to  the  move,  take  on  at  once  an  unhealthy  appear- 
ance ;  some  slough,  erysipelas  or  mortification 
shows  itself  in  others,  and  all  feel  more  or  less  its 
malignant,  injurious  influence,  even  with  the  best 
transports,  and  under  the  most  favorable  circum- 
stances.    The  jolting  of  a  broken  limb  for  three 


82  HAND    UTTERS. 

or  four  hours  over  a  rough  road  is  indescribable 
torture.  The  prostration  and  exhaustion  depicted 
upon  the  faces  of  the  wounded  after  such  a  trans- 
fer, explains  at  once  the  problem  of  why  many 
should  die  during  the  transportation,  and  makes 
us  wonder  how  so  many  escape  with  life,  after 
undergoing  such  unutterable  hardships. 

Litters. — The  common  and  best  means  of 
moving  wounded  men  for  short  distances  is 
•upon  litters,  which  may  be  prepared  in  advance, 
or  be  an  impromptu  manufacture.  In  case  of 
necessity  a  litter  can  at  once  be  made  from  the 
blanket  of  a  soldier.  This  is  doubled  upon 
itself,  a  slit  being  made  through  the  end  cor- 
ners, sufficiently  large  to  admit  the  barrel  of  a 
musket;  one  musket  is  passed  through  the  fold 
of  the  blanket,  another  through  the  slits  in  the 
ends,  and  a  litter  is  ready  for  use.  Soldiers' 
blankets  are  at  times  prepared  for  this  service,  by 
having  strong  loops  sewed  to  the  corners,  so  that 
when  the  blanket  is  doubled  the  four  loops  will 
come  on  one  straight  side ;  one  musket  is  passed 
through  the  four  loops,  the  second  through  the 
folded  blanket.  Where  comrades  from  the  ranks 
are  expected  to  carry  off  the  wounded,  this  is  the 
onlv  litter  which  is  of  service,  as  any  two  soldiers 


HAND    LITTERS. 


83 


arc  prepared  to  act  as  transports,  without  hamper- 
ing themselves  during  the  fight  with  extra  bag- 
ijaii'e. 

Such  a  litter  is,  however,  very  defective,  as  the 
weight  of  the  patient  sags  the  yielding  blanket 
until  it  nearly  reaches  the  ground,  whilst  the  mus- 
kets are  pressed  in  upon  the  haunches  of  the 
bearers,  which  renders  it  impossible  for  them  to 
proceed  with  ease  or  celerity.  The  proper  litter 
or  stretcher  is  made  of  strong  sacking  or  canvas, 
six  feet  four  inches  long  and  two  feet  wide.  A 
broad  hem  is  taken  up  on  either  side,  through 
which  passes  readily  a  stout  pole,  ten  feet  long. 
On  either  side  of  the  litter  is  an  iron  rod  two  feet 
wide,  with  rings  at  the  ends,  which  slip  over  the 
poles  and  form  the  stretcher,  to  keep  the  poles 
separate,  and  prevent  any  sagging  of  the  litter. 
Two  iron  projections  from  these  rods,  eight  to 
twelve  inches  in  length,  will  serve  as  feet  for  the 
litter,  and  will  be  found  very  useful  in  relieving 
the  carriers,  as  they  can  then  rest  themselves 
when  travelling  over  uneven  ground,  without  the 
wounded  man  being  annoyed  by  the  irregularities 
of  the  surface.  A  shoulder  strap,  with  a  loop  on 
either  end  to  receive  the  poles,  completes  an  appa- 
ratus which  is  capable  of  carrying  off  a  wounded 
man  with  all  the  comfort  with  which  his  situation 


84  FRAMED    LITTERS. 

admits.  A  pike  head  attached  to  the  pole  makes 
it  a  formidable  weapon  of  defence.  Each  of  those 
who  are  expected  to  transport  the  wounded  is 
armed  with  such  a  pike,  and  has  one  iron  traverse 
or  stretcher  and  canvas  bottom  strapped  upon  his 
knapsack.  Any  two  of  them  meeting  together 
will  be  enabled  in  a  few  minutes  to  equip  an 
efficient  litter.  When  placed  in  the  litter,  the 
soldier's  knapsack  is  placed  under  his  head  as  a 
pillow,  and  his  musket  lies  alongside  of  him,  or 
may  be  hung  from  the  side  of  the  litter  by  loops 
placed  there  for  that  purpose. 

A  framed  litter  is  one  of  very  questionable  utility, 
as  it  is  a  very  bulky  article,  and  one  easily  broken, 
so  that  usually,  after  a  long  transportation,  very 
few  of  them  are  tit  for  service. 

Williamson,  in  his  Notes  on  the  Wounded  from 
the  Mutiny  in  India,  published  in  1859,  has,  in  the 
appendix,  a  plate  and  description  of  a  dooley — a 
kind  of  litter  used  for  the  conveyance  of  the  sick 
and  wounded  in  India.  In  the  field  service  it 
forms  the  patient's  bed  as  well  as  means  of  convey- 
ance from  the  time  of  his  being  wounded  until  he 
is  either  cured  or  dies.  It  consists  of  a  frame- 
work resembling  a  bedstead  in  miniature,  six  and 
a  half  by  two  feet,  with  light  posts,  which  run 
below  the  bed  six  inches.     This  is  slung  by  two 


HORSE   LITTERS.  85 

ropes  placed  on  either  side  from  the  head  and 
foot,  and  running  up  triangularly,  the  pole  upon 
which  the  litter  is  supported  passing  through 
the  apex  of  these  two  triangles.  A  tarpaulin 
cover,  with  side  curtains,  excludes  the  sunlight 
and  gives  privacy  to  the  wounded.  When  the 
bearers  arrive  at  the  encampment,  they  run  the 
dooley  into  the  hospital  tent,  take  out  the  pole 
with  the  tarpaulin  covering  and  curtains,  with 
which  they  make  their  tent,  leaving  the  patient 
comfortably  in  his  bed.  These  were  found  to 
answer  admirably  in  the  Crimea,  where  they  were 
used  to  a  limited  extent.  This  is  the  most  com- 
fortable conveyance  for  a  sick  or  wounded  per- 
son, and  its  introduction  generally  into  the  Eng- 
lish service  has  been  strongly  recommended. 

Horse  Litters. — Next  to  hand  litters  for  the 
transportation  of  wounded  men  are  horse  litters, 
made  three  feet  wide  with  poles  sixteen  feet  long. 
Horses  or  mules  take  the  place  of  men,  the  poles 
acting  as  shafts,  and  supported  by  back  straps  or  by 
a  saddle  with  tugs,  as  in  ordinary  harness.  Each 
horse  litter  carries  two  persons.  When  the  mules 
are  led  by  men  well  trained  for  this  duty,  trans- 
portation by  this  means  is  well  suited  to  the 
comfort   of  the    wounded;    but  if   the    muleteers 


<Q(3  AMBULANCE    CARRIAGES. 

are  raw  hands,  who,  holding  the  mule  by  the 
head,  attempt  to  lead  it,  instead  of  allowing  it 
to  pick  its  own  way,  the  joltings  and  sudden 
jars  make  this  litter  anything  but  a  bed  of  down. 

The  French  use  largely  what  is  called  a  cacolet, 
a  kind  of  arm  chair,  which  is  suspended  on  either 
side  of  the  saddle  upon  a  mule.  It  offers  a  com- 
fortable seat  for  the  wounded,  and  each  mule  can 
carry  comfortably  two  men  from  the  field  to  the 
infirmary.  In  hilly  countries,  over  bad,  rough 
roads,  this  is  found  a  much  better  conveyance 
than  vehicles. 

The  two  and  four  wheel  carriage  or  ambulance 
wagons,  which  have  been  adopted  in  every  civil- 
ized army,  are  considered  indispensable  for  field 
service,  and  for  the  transportation  of  the  wounded. 
The  two-wheeled  vehicle  is  the  most  comfortable. 
Both  two  and  four  are  so  arranged  as  to  allow  of 
the  wounded  being  carried  lying,  reclining,  and 
sitting.  The  omnibus  is  the  most  expeditious 
means  of  removing  those  lightly  wounded  but  not 
able  to  walk  from  the  field.  Where  the  roads  are 
good,  in  an  open  country,  this  vehicle  should  not 
be  neglected. 

The  Confederate  service,  based  upon  the  army 
regulations  of  the  United  States,  allows  for  every 
command  of  less  than  three  companies  one  two- 


MEDICAL    SERVICE    OF    AN    ARMY.  S7 

wheeled  transport  cart  for  hospital  supplies,  and 
to  each  company  one  two-wheeled  ambulance  car- 
riage. For  commands  of  more  than  three  or  less 
than  five  companies,  two  two -wheeled  transport 
carts,  and  to  each  company  one  two-wheeled  am- 
bulance carriage.  For  a  battalion  of  five  compa- 
nies, one  four-wheeled  ambulance  carriage,  five 
two-wheeled  and  two  two-wheeled  transport  carts; 
and  for  each  additional  company  less  than  ten,  one 
two-wheeled  transport  cart.  For  a  regiment,  two 
four-wheeled  ambulance  wagons,  ten  two-wheeled 
ambulance  wagons,  and  four  two-wheeled  trans- 
port carts. 

Medical  Service  of  the  Army. — The  medical 
service  of  an  army  in  times  of  peace  is  selected 
with  care  by  an  examining  board,  whose  rigid 
inquiries  into  the  literary  and  professional  attain- 
ments, as  well  as  into  the  moral  and  physical  con- 
dition of  the  applicant,  keeps  the  staff  purged  of 
inferior  men,  and  forms  a  body  of  scientific  inves- 
tigators whose  efficiency  will  compare  favorably 
with  the  profession  of  any  country. 

During  war,  the  medical  department  increases 
■pari  passu  with  the  army.  These  appointments 
should  be  made  with  a  full  knowledge  of  the 
weighty  responsibilities   attached  to  the  medical 


OS  CONFEDERATE    .MEDICAL    SERVICE. 

staff,  without  whose  constant  solicitude  for  the 
health  and  well-being  of  the  troops  committed  to 
their  care,  the  effective  strength  of  an  army  will 
be  materially  reduced.  With  a  view  to  ensure  the 
most  active  and  efficient  treatment  of  the  sick  in 
the  army  at  all  times,  and  particularly  during 
active  service,  it  is  not  only  essential  that  the 
medical  officers  should  be  men  of  ability  and  of 
high  professional  qualifications,  but  that  they 
should  possess  physical  energy  adequate  to  the 
more  arduous  duties. 

The  advantages  of  having  an  experienced  surgi- 
cal staff  in  the  field,  and  the  influence  which  it 
can  exert  on  the  vicissitudes  of  war,  must  be 
acknowledged  by  every  thinking  man.  Yet  medi- 
cal advice  is  seldom  asked  or  listened  to  by  those 
in  command,  so  long  as  suffering  and  death  are 
not  cruelly  felt.  The  proper  understanding  be- 
tween the  medical  and  military  staff  of  an  army, 
with  concert  of  action,  will  save  many  a  8010110", 
who  would  otherwise  lose  or  compromise  his  life, 
so  valuable  to  the  country  in  times  of  need. 

In  the  Confederate  service,  each  regiment  of 
one  thousand  men  has  one  surgeon  and  one  assist- 
ant surgeon.  These  in  times  of  peace  are  found 
scarcely  sufficient  to  attend  to  the  sick,  and  in 
times  of  epidemics  or  war  they  are  incompetent 


ENGLISH    MEDICAL    SERVICE.  89 

to  offer  that  assistance  which  sick  and  wounded 
require.  Many  a  life  has  been  sacrificed  to  pro- 
crastination. Upon  the  first  and  immediate  atten- 
tion to  the  wounded  on  the  battle  field  depends  in 
a  great  measure  the  success  of  treatment;  and  in 
any  encounter  which  deserves  the  name  of  a  battle 
the  wounded  must  necessarily  be  neglected  by  this 
deficient  medical  staff.  Our  experience  in  the 
Mexican  war  proved  the  inefficiency  of  our  sparse 
medical  corps.  European  experience  confirms  the 
observation  that  two  medical  men  are  not  suffi- 
cient to  take  care  of  the  health  of  a  regiment. 
This  was  the  subject  of  general  comment  in  the 
Crimea,  where  the  medical  staff  were  unanimous 
in  the  demand  for  additional  medical  assistance. 
In  active  service,  every  regiment  should  have  at 
least  one  surgeon  and  two  assistant  surgeons,  these 
differing  only  in  rank,  their  duties  being  similar. 
Besides  the  regular  regimental  surgeons,  there 
should  be  a  medical  reserve  corps  to  take  charge 
of  military  hospitals,  whilst  regimental  officers 
accompany  their  commands. 

In  the  English  service,  the  medical  department  is 
composed  of  regimental  surgeons,  with  their  assist- 
ants, staff  surgeons  of  the  first  and  second  class, 
and  medical  inspectors.  The  staff  surgeons  of  the 
first  class  rank  the  regimental  surgeons,  and  with 
S 


UU  FRENCH    MEDICAL    SERVICE. 

their  assistants  either  take  charge  of  military  hos- 
pitals or  act  as  medical  supervisors  for  a  brigade, 
composed  of  three  or  more  regiments.  The  assist- 
ant staff'  surgeon  holds  the  same  rank  as  the  regi- 
mental surgeon.  When  many  brigades  are  collected 
into  a  division,  a  staff'  surgeon  of  long  service  is 
appointed  to  direct  the  medical  and  surgical  affairs 
of  the  division ;  and  when  a  large  force,  consisting 
of  several  divisions,  with  their  respective  generals 
and  physicians,  is  brought  into  the  field  for  actual 
service,  and  placed  under  a  general  in  chief,  a 
medical  staff  officer,  bearing  the  title  of  inspector 
general,  is  appointed  to  superintend  and  concen- 
trate all  the  movements  of  the  medical  depart- 
ment of  the  army.  The  medical  department  takes 
the  military  therefore  as  its  model. 

In  the  French  army,  a  somewhat  similar  organi- 
zation is  found.  Besides  surgeons  and  assistant 
surgeons  attached  to  regiments,  the  military  hos- 
pital staff,  which  is  a  very  numerous  one,  consists 
of  medical  inspectors  or  head  surgeons  of  infirma- 
ries, staff"  surgeons  of  the  first  class,  with  senior 
and  junior  assistants,  the  number  detailed  for 
special  hospital  duty  depending  upon  the  size  of 
the  institution  and  the  number  of  its  inmates. 

The    most    thorough    medical    organization    in 


PRUSSIAN    MEDICAL    SERVICE.  (J  1 

Europe  belongs  to  the  Prussian  service,  and  is 
composed  as  follows: 

Each  battalion  of  one  thousand  men  has  a 
surgeon  and  a  distant  surgeon,  who  are  thoroughly 
instructed  in  the  duties  which  they  are  expected 
to  perform.  Besides  these,  there  is  to  every  coi-j's 
cfarmte  of  thirty  thousand  men,  a  staff  of  forty 
surgeons,  who,  in  time  of  war,  take  charge  of  the 
general  military  hospitals  opened  for  the  reception 
of  the  sick  and  wounded.  This  division  has  also 
attached  to  its  medical  department- three  infirmary 
staffs  for  light  field  service,  composed  of  eleven 
surgeons  each.  These  act  as  a  reserve  on  the  battle 
field,  opening  field  infirmaries  which  follow  the 
troops  and  give  the  first  aid  and  dressing  to  the 
wounded.  This  gives  a  proportion  of  nine  sur- 
geons to  every  two  thousand  men;  and,  notwith- 
standing this  large  number,  there  are  periods 
when  even  a  larger  number  of  surgeons  would 
not  be  sufficiently  numerous  to  give  proper  and 
immediate  assistance  to  the  wounded.  In  most 
European  armies  the  dispensing  of  medicines  is 
performed  by  apothecaries,  who  complete  the 
medical  organization.  In  the  English  and  Ameri- 
can service  the  assistant  surgeon  acts  as  apothe- 
cary. 

In  recent  European  campaigns  a  very  important 


92  SANITARY  CORPS  OR  CARRIERS. 

addition  has  been  made  to  the  surgical  service. 
It  is  the  sanitary  corps  or  carriers  of  the  'wounded. 
Heretofore,  when  men  were  shot  down  from  the 
ranks,  they  were  borne  to  the  back  by  their  com- 
rades in  arms,  who  transported  them  to  the  field 
infirmaries,  where  the  surgeons  attended  to  their 
wounds.  Although  a  most  praiseworthy  act  of 
devotion  to  a  fallen  friend,  it  was  often  called  for 
when  help  could  least  be  spared,  as  the  taking 
away  of  so  many  fighting  men  from  the  ranks 
enfeebles  the  strength  of  the  command,  if  it  does 
not  break  up  the  corps.  It  is  also  well  known,  that 
if  any  from  the  ranks  are  drawn  from  the  fight  to 
carry  off  the  wounded,  they  never  return  until  the 
fight  is  over,  and  thus  three  are  lost  to  the  com- 
pany instead  of  the  one  wounded.  Besides,  with 
the  very  best  intentions,  these  comrades  are  not 
instructed  how  to  carry  the  wounded  so  that  they 
should  suffer  least  detriment,  and  the  final  result 
cannot  be  but  injurious  to  the  wounded.  The 
sanitary  corps,  which  now  forms  a  very  essential 
part  of  continental  armies,  and  has  been  strongly 
recommended  to  the  English  service  by  the  sur- 
gical staff  of  the  army,  is  a  regularly  organized 
body,  who  are  taught  how  to  carry  wounded  men. 
These  practiced  hands  are  under  military  disci- 
pline, with   officers  whose   duty  it  is  to  see  that 


SANITARY  CORPS  OR  CARRIERS.  9o 

the  wounded  are  promptly  and  carefully  removed 
from  the  places  where  they  fall  to  the  infirmaries. 
There  are  surgeons  connected  with  this  sanitary 
corps  to  attend  to  the  judicious  transportation. 
They  only,  offer  temporary  assistance.  Should 
there  be  fearful  hemorrhage  they  may  apply  a 
tourniquet,  or  show  the  assistants  how  to  compress, 
effectually,  the  bleeding  vessel;  if  a  chest  wound, 
they  may  at  once  open  a  vein  to  prevent  the 
soldier  dying  in  transit.  They  arrange  broken 
limbs  so  as  to  be  conveyed  with  most  comfort,  and 
give  a  dose  of  morphine  when  much  suffering  is 
felt,  but  beyond  this  temporary  assistance  they 
never  go.  This  sanitary  corps,  with  litters,  ambu- 
lance wagons,  pack  horses,  and  all  other  facilities 
for  transporting  wounded  men,  should  be  in  the 
advance,  immediately  behind  the  troops,  when  the 
battle  is  going  on.  Their  post  is  one  of  risk  as 
well  as  of  responsibility.  ISTot  unfrequently  they 
lose  their  lives  in  accomplishing  their  benevolent 
tasks.  Both  humanity,  civilization  and  economy 
dictate  that  a  similar  corps  should  be  appended  to 
every  army  in  the  field.  When  not  wanted  on 
the  battle  field,  experience  makes  them  careful 
nurses  upon  the  wounded. 

The  folloiuing  is  the  course  pursued  by  the  Prussian 
medical  corps  of  a  division  of  thirty  thousand  men 


94  SANITARY    COUPS    Oil    CARRIERS. 

xch.cn  going  into  battle:  The  reserve  corps  of  forty 
surgeons  establish  a  general  hospital  at  some  safe 
and  convenient  point,  four  or  five  miles  from  the 
battle  field.  Here,  all  the  appliances  are  concen- 
trated for  giving  proper  attention  to  the  injured. 
Here,  most  of  the  serious  and  tedious  operations 
are  to  be  performed,  under  judicious  consultation. 
As  this  is  the  resting  place  from  the  field,  accom- 
modations must  be  ample,  and  every  facility  for 
treating  successfully  the  seriously  wounded  must 
therefore  be  found,  and  all  hospital  stores  should 
be  concentrated  at  this  hospital. 

Directly  behind  the  line  of  battle,  and  mov- 
able with  it,  are  placed  the  light  field  infirm- 
aries with  their  special  staffs.  They  are  the 
main  stations  for  medical  service,  as  all  the 
wounded  pass  through  these  on  their  way  to  the 
general  hospital.  At  these  field  infirmaries,  the 
wounded  receive  the  first  thorough  examination. 
Many  operations  deemed  imperative  are  here  per- 
formed. All  wounds  are  here  cleansed,  foreign 
bodies  of  every  kind  extracted,  hemorrhage  con- 
trolled, and  the  first  proper  dressing  applied.  As 
the  wounded  are  brought  to  this  point  as  they  are 
shot  down,  their  wounds  have  undergone  but  little 
change ;  the  system  is  still  suffering  from  a  certain 
amount    of  nervous   shock,   which    makes  it  the 


SANITARY  CORPS  OR  CARRIERS.  95 

proper  time  for  effecting  a  thorough,  examination 
without  giving  pain. 

In  these,  as  in  the  general  hospital,  there  is 
always  a  division  of  labor,  and  each  surgeon, 
knowing  his  duty,  accomplishes  the  greatest 
amount  of  work  in  his  special  department.  The 
division  always  recognized,  is  the  examiner,  the 
operator,  and  the  dresser.  Those  who  are  most 
skilled  in  these  various  departments  are  expected 
to  give  the  benefit  of  their  skill  and  experience  to 
the  wounded.  More  importance  is  placed  upon 
these  subdivisions  of  labor  than  we  would,  at  first 
sight,  recognize.  It  is  well  known  that  many 
hands  can  be  efficiently  worked  by  one  head,  and 
that  when  a  surgeon  of  much  experience  and 
mature  judgment  determines  what  course  should 
be  pursued,  there  are  many  competent  to  carry 
out  his  suggestions,  who  were  not  sufficiently 
prepared  to  establish  a  thorough  diagnosis  and 
foresee  the  probable  issue. 

The  importance  of  examining  a  wound  as  sel- 
dom as  possible  being  acknowledged,  it  is  easy 
to  understand  why  the  most  proficient  surgeons 
in  the  service  should  be  appointed,  as  diagnos- 
ticians, to  examine,  thoroughly,  the  wounded 
and  determine  upon  a  course  of  treatment.  In 
gunshot  wounds,  above  all    others,   the   necessity 


96  SANITARY  CORPS  OR  CARRIERS. 

for  accurate  diagnosis  becomes  imperative,  and 
this  first  examination  should  never  be  slurred 
over,  however  urgent  the  demands  upon  the  sur- 
geon's time.  Except  in  very  obscure  cases,  an  after- 
examination  should  never  be  made,  as  it  always  gives 
pain,  increases  irritability,  heightens  inflammation 
and  permits  air  to  gain  access  to  the  very  depth 
of  the  wound,  which  is  sure  to  promote  the  de- 
composition of  the  exudates  around  the  wound, 
with  its  suppurative  and  sloughing  sequelae.  Many 
a  limb  and  life  would  be  preserved  were  it  possible  to 
limit  the  examination  of  the  wounded  to  the  battlefield. 
Let  it  be  remembered  that  the  first  examination 
is  always  less  painful  and  dangerous  than  any  sub- 
sequent one.  All  surgeons  agree  upon  the  suc- 
cess of  primary  operations,  when  compared  to 
secondary,  after  inflammation  has  set  in.  How  to 
proceed  or  what  wounds  to  condemn  requires  nice 
discrimination,  hence  the  necessity  of  devoting 
the  talent  and  experience  of  the  staff  to  this  very 
important  duty. 

In  the  Prussian  service,  the  regimental  surgeons 
are  concentrated  in  groups  with  their  assistants, 
rather  than  follow  their  respective  regiments  into 
the  fire.  Thus  much  time  is  saved  and  the 
wounded  receive  more  attention,  and  keeping 
them  together  in  this  way  renders  it  easy  to  com- 


SANITARY  CORPS  OR  CARRIERS.  Vl 

mand  medical  service  when  it  may  be  needed  for 
any  special,  extra  duty.  This,  of  course,  does  not 
prevent  surgeons  being  sent  to  various  points  of 
the  line,  to  assist  the  medical  portion  of  the  sani- 
tary corps  in  the  proper  transportation  of  the 
wounded.* 

In  the  same  service,  the  primary  dressings  for  the 
wounded  are  carried  by  each  soldier,  so  that  all 
necessary  bandages  are  on  the  spot,  and  no  time 
is  lost  waiting  for  the  bandage  boxes  or  hos- 
pital stores.  The  general  plan  adopted  by  the 
entire  army  is  as  follows :  Every  soldier  car- 
ries a  small  package  three  inches  long  and  one 
inch  thick,  which  contains  the  following  articles, 
viz:  two  pieces  of  old,  soft,  clean  linen,  nine 
inches  square;  a  piece  of  oiled  silk  or  india- 
rubber  tissue,  nine  inches  long  by  five  inches 
wide;  a  small  ball  of  lint;  a  bandage  two  and 
a  half  yards  long  and  two  inches  in  width.  One 
piece  of  the  linen  is  folded  double  and  rolled 
tightly  over  the  lint,  and  over  this  the  piece  of 
oiled  silk  is  rolled,  the  bandage  rolled  around 
this,  and  the  whole  enveloped  in  the  second 
piece  of  linen  and  fastened  with  two  pins.  This 
should  be  put  in  a  particular  place  in  the  knap- 
sack,   where   it    can    always   be    found.       Should 

*Loeffler.     Behaudlung  der  Scliusswuude;  Berlin,  1859. 


98  SURGICAL    STAFF, 

there  be  two  wounds,  the  oiled  silk  and  cloth 
may  be  divided  to  make  a  double  dressing,  and 
one  piece  of  cloth  may  be  used  by  the  sur- 
geon as  a  towel.  In  this  small  but  very  useful 
package  is  found  the  requisite  dressings  for  every 
gunshot  wound.  It  saves  the  surgeon  the  annoy- 
ances  and  delays  incidental  to  the  transportation 
of  hospital  stores.  In  the  light  field  infirmaries, 
nearly  all  the  dressings  of  the  wounded  are  ob- 
tained from  this  individual  package,  the  very  few 
extra  articles  needed  being  furnished  from  the 
iufirmary  supplies. 

Stromyer,  in  his  surgical  writings  on  the  Schles- 
wig-Holstein  war,  speaks  of  the  medical  depart- 
ment of  the  army  as  modelled  upon  the  military. 
Beside  the  regimental  surgeons,  each  brigade  had 
a  brigade  surgeon  with  three  assistants.  The 
larger  divisions  of  the  army  were  equally  supplied 
with  superior  medical  officers  and  staff.  On  the 
battle  field  the  surgeons  of  the.  army  established 
infirmaries  for  the  immediate  care  of  the  wound- 
ed, who  were,  after  the  first  dressings,  sent  into 
the  more  permanent  infirmaries. 

In  the  Confederate  service,  where  so  small  a 
surgical  staff  is  recognized,  we  will  be  compelled 
to  take  advantage  of  the  railroad  facilities  of  trans- 


CONFEDERATE    SERVICE.  99 

portation,  and  use  the  hospitals  of  those  cities 
contiguous  to  the  scene  of  encounter,  with  volun- 
teer surgical  aid  as  our  reserve  corps.  This  will 
not  diminish  the  arduous  duties  of  the  regimental 
surgeons  and  their  assistants,  who  will  find  con- 
stant employment  whilst  in  camp  and  on  the 
battle  field;  in  spite  of  their  unceasing  efforts, 
the  wounded  cannot  but  be  wofully  neglected. 
Modern  warfare,  in  introducing  arms  of  precision, 
of  immensely  increased  range,  and  perfected  in- 
struments of  destruction,  has  created  a  new  era 
in  military  surgery.  The  conical  ball  of  double 
weight  has  become  the  common  missile,  and  when 
discharged  from  a  rifle  it  flies  with  fearful  velocity. 
Such  balls*,  when  traversing  soft  parts,  produce 
extensive  destruction,  but  seldom  bury  themselves. 
Comparatively  few  of  these  are  to  be  extracted 
after  a  battle.  Should  they  impinge  upon  a  bone, 
the  splitting  and  crushing  is  extensive ;  large 
spicula?  are  driven  in  every  direction,  transfixing 
limbs  and  even  impaling  those  standing  in  the 
neighborhood.  In  Crimean  experience,  a  serious 
wound  was  sometimes  inflicted  by  a  large  frag- 
ment of  bone  driven  from  a  neighboring  soldier. 
The  extensive  injury  to  bones  necessitates  more 
frequent  amputations  and  resections.  This  coni- 
cal  ball    seldom   fails   to   take    the    shortest   cut 


100  CAMP   DUTIES    OF    SURGEON. 

through  a  cavity  or  limb,  and  it  has  at  times  been 
seen  to  pass  through  the  bodies  of  two  men  and 
lodge  in  that  of  a  third.  Those  who  compare 
the  dead  on  recent  battle  fields  with  those  of 
former  wars  are  painfully  struck  with  the  greater 
mutilation  of  the  bodies  from  conical  balls.  Rarely 
are  they  deflected  from  their  course,  as  is  the 
round  ball,  which  is  turned  by  every  little  obsta- 
cle, and  takes  up  a  position  at  striking  variance 
with  any  rule  of  propulsive  forces.  In  steady 
hands,  frightful  wounds  are  produced  by  the 
Minie  ball,  which  requires  all  the  resources  of 
surgery  to  successfully  counteract. 

Let  us  now  define  the  duties  of  a  surgeon  in  the 
Confederate  service,  both  in  camp  life  and  on  the 
battle  field. 

Camp  Duties  of  a  Regimental  Surgeon. — We 
have  already  shown  that  the  fire  of  an  enemy 
never  decimates  an  opposing  army.  Disease  is 
the  fell  destroyer  of  armies,  and  stalks  at  all  times 
through  encampments.  Where  shot  has  destroyed 
its  hundreds,  insidious  diseases,  with  their  long 
train  of  symptoms  and  quiet,  noiseless  progress, 
sweep  away  their  ten  thousands.  To  keep  an 
army  in  health  is,  then,  even  more  important  than 
to  cure  wounds   from   the  battle  fields.     But,  as 


CAMP    DUTIES    OP    SURGEON.  101 

surgeons  in  the  service  are  expected  to  be  skilled 
in  both  departments,  so  that,  in  either  case,  the 
troops  under  their  care  should  suffer  no  detriment, 
they  should  be  thoroughly  prepared  for  the  very 
responsible  positions  which  they  fill.  Conserva- 
tive surgery  requires  much  more  at  the  hands  of 
the  surgeon  than  the  destructive  practice  of  former 
times.  Every  surgeon  should  now  prepare  himself 
for  the  field,  by  familiarizing  himself  with  opera- 
tive surgery.  Half  knowledge  leads  into  meddling, 
which  is  far  worse  than  no  surgical  assistance. 
Many  a  wounded  soldier  has  felt  heavily  the  busy  hand 
of  the  willing  surgeon  who  lacked  the  guiding  head. 
The  surgeon  has  charge  of  a  number  of  very 
valuable  lives,  and  the  necessity  imposed — by  the 
absence  of  consulting  aid — of  deciding  the  most 
serious  and  critical  cases  upon  his  own  unaided 
judgment  demands,  upon  his  part,  self-reliance, 
which  can  only  be  based  upon  previous  prepara- 
tion. Camp  life  gives  a  surgeon  much  food  for 
thought  and  ample  personal  experience,  but  gives 
him  no  time  to  consult  authors  and  improve  him- 
self with  books.  He  does  not  see  so  great  a 
variety  of  diseases  as  are  met  with  in  civil  prac- 
tice, but  he  has  a  wider  field  for  observing  the 
influences  of  external  modifying  circumstances, 
as   exposure,   improper  food,   imperfect  clothing, 


102  CAMP    DUTIES    OF    SURGEON. 

irregular  work,  want  of  cleanliness,  and  depressing 
or  exhilarating  mental  influences.  The  diseases 
of  a  soldier,  like  those  of  most  trades,  are  pecu- 
liar, each  trade  begetting  its  own,  whilst  it  gives 
immunity  to  others.  The  greater  uniformity  in 
age,  constitution,  modes  of  living,  exposure  to 
similar  external  influences,  and  strict  discipline, 
modify  to  a  considerable  extent  the  diseases  of 
camp.  It  is  especially  the  crowding  together,  with 
the  animal  emanations  from  such  a  number  of 
living  beings,  that  gives  character  to  the  phases 
of  disease. 

The  preservation  of  the  health  of  the  soldier  being 
the  sole  duty  of  the  military  surgeon,  he  will  be 
expected  to  use  every  means  within  his  reach  to 
attain  this  desirable  end,  especially  by  a  rigid  ob- 
servance of  those  forms  of  discipline  and  economy 
which  are  under  the  direction  and  surveillance  of 
the  military  officers.  As  diseases  will  arise  among 
troops,  and,  as  very  few  of  these  cannot  be 
arrested  by  means  of  art  when  skilfully  applied 
at  an  early  period,  care  should  be  taken  that 
medical  skill  be  promptly  resorted  to  at  the  very 
first  sign  of  indisposition.  Hygiene  must  first 
claim  his  attention;  under  the  adage,  prevention 
is  better  than  cure.  If  the  troops  are  about  going 
into  camp  he  must  examine  the  ground  and  see 


CAMP    DUTIES    OF    SURGEON.  103 

whether  any  causes  exist  for  rendering  the  place 
insalubrious.  When  in  a  friendly  country  he 
should  seek  information  from  the  local  physi- 
cians, which  will  not  only  give  him  a  better 
insight  into  the  sanitary  condition  of  the  point 
selected,  but  will  also  instruct  him  upon  the 
diseases  prevalent  in  the  locality,  and  the  means 
which  local  experience  and  observation  have 
proved  most  effective  in  controlling  such  dis- 
eases. He  must  see  that  the  troops  in  camp  are 
supplied  with  dry  straw  for  beds,  and  that  they 
air  the  same  with  their  tent  daily,  so  as  to 
ensure  a  healthy  place  for  repose,  and  report 
any  neglect  to  the  commanding  officer.  He  must 
see  that  the  soldiers  are  properly  clothed  and 
well  fed  with  wholesome,  nutritious  food,  and 
supplied  with  an  abundance  of  good  water,  and, 
from  time  to  time,  should  suggest  to  the  com- 
manding officer  such  changes  in  the  diet  as  will 
be  conducive  to  the  health  of  the  command.  If 
the  water  is  bad,  he  should 'study  how  it  can  be 
improved,  so  as  not  to  act  injuriously  upon  the 
men.  Cleanliness  of  the  encampment  and  of 
the  tent,  with  frequent  ablutions  of  the  body 
and  clothing  of  soldiers,  should  never  be  absent 
from  his  thoughts.  He  should  point  out  to  the 
commanding  officer  all    nuisances  which  promise 


104  CAMP    DUTIES    OF    SURGEON. 

to  be  detrimental  to  the  health  of  the  corps,  and 
urge  their  removal,  suggesting  how  they  can 
best  be   disposed  of. 

The  hospital  tents  will  be  pitched  upon  a 
dry,  well-drained  spot,  if  a  building  cannot  be 
obtained  for  the  same,  and  it  is  the  duty  of 
the  regimental  surgeon  to  attend  to  the  proper 
furnishing  of  the  same  with  all  possible  conve- 
niences for  the  sick.  He  will  enforce  all  proper 
hospital  regulations  to  promote  health  and  pre- 
vent contagion,  by  ventilation,  scrupulous  clean- 
liness,   frequent  changes    of  bedding,  linen,    etc. 

At  the  morning  surgeon's  call,  the  sick  of  the 
regiment  will  be  conducted  to  the  hospital  by 
the  first  sergeants  of  the  various  companies,  who 
will  each  hand  to  the  surgeon  a  list  of  all  the 
sick  of  the  company,  on  which  the  surgeon  will 
state  who  are  to  remain  or  go  into  hospital ; 
who  are  to  return  to  quarters  as  sick  or  con- 
valescent ;  what  duties  the  convalescents  in  quar- 
ters are  capable  of  performing;  what  cases  are 
feigned,  and  any  other  information  in  regard  to 
the  sick  of  the  company  he  may  have  to  com- 
municate to  the  company  commander.  He  will 
then  distribute  the  patients  in  the  hospital, 
see  that  they  are  properly  provided  writh  com- 
fortable beds;   enter   in    the   proper   register   the 


CAMP    DUTIES    OF    SURGEON.  105 

name,  the  case,  the  disease;  and  in  the  diet  and 
prescription  book  the  medicines  which  the  case 
requires.  If  his  assistant  is  not  present,  he 
prepares  the  medicines  and  superintends  their 
administration.  He  will  visit  the  hospital  each 
day  as  frequently  as  the  state  of  the  sick  may 
require.  Should  any  soldier  be  taken  suddenly 
sick,  his  case  is  at  once  reported  to  the  surgeon, 
who  will  visit  and  prescribe  for  him  in  his  tent, 
unless  the  case  threaten  to  be  serious,  when  he 
should  be  removed  without  delay  to  the  hospital. 

Convalescents,  on  coming-  out  of  the  hospital, 
are  not  to  be  put  on  duty  till  the  surgeon  certifies 
to  the  commanding  officer  that  they  have  perfect- 
ly recovered ;  for  which  purpose  it  is  the  duty  of 
the  surgeon  to  make  (daily)  a  particular  inspection 
of  these  men  at  morning  parade,  to  prevent  any 
remaining  longer  exempt  from  duty  than  the  state 
of  their  health  renders  absolutely  necessary.  After 
the  surgeon's  call,  he  will  make  a  morning  report 
of  all  the  sick  and  disabled  to  the  commanding 
officer.  He  also  recommends  that  leave  of  absence 
be  granted  on  furlough  to  those  convalescents  who 
will  recover  more  rapidly  by  change  of  scene  and 
life. 

The  senior  medical  officer  of  a  post,  hospital, 
regiment,  or  detachment,  will  make  monthly,  to 


10G  DUTIES    OF    ASSISTANT    SURGEON. 

the  medical  director,  and  quarterly,  to  the  surgeon- 
general,  a  report  of  the  sick  and  wounded,  of 
deaths,  and  certificates  granted  for  discharge  from 
disability,  and  transmit  to  him  the  same,  with  a 
statement  of  the  hospital  fund.  He  will  also  keep 
the  following  records,  from  which  the  condensed 
report  to  the  superior  medical  officer  is  drawn, 
viz :  a  register  of  patients ;  a  prescription  book  ; 
a  diet  book ;  a  case  book ;  copies  of  his  requisi- 
tions; annual  returns,  and  reports  of  sick  and 
wounded  ;  and  an  order  and  letter  book,  in  which 
will  be  transcribed  all  orders  and  letters  relating 
to  his  duties.  All  requisitions  for  hospital  and 
medical  stores  must  come  from  the  senior  surgeon, 
with  the  approval  of  the  commanding  officer,  cer- 
tifying that  the  same  are  necessaiy  for  the  sick. 

The  duties  of  the  assistant  surgeon  are  very  similar 
in  many  respects  to  those  of  the  surgeon.  If  he 
has  the  confidence  of  the  regimental  surgeon,  the 
patients  are  equally  divided  between  them;  he 
treating  a  certain  number  of  sick  ordinarily  with- 
out interference  from  the  senior  surgeon,  except 
they  be  serious  cases,  when  he  seeks  advice  from 
the  regimental  surgeon.  Although  this  is  the  com- 
mon course  pursued,  it  is  not  so  from  right,  but 
by  sufferance  of  the  senior  surgeon.     In  the  army 


DUTIES    OF    ASSISTANT    SURGEON.  107 

regulations,  the  senior  surgeon  being  the  superior 
officer,  the  assistant  surgeon  is  under  his  control. 
He  is  supposed  to  do  merely  the  medical  duties 
when  the  surgeon  is  present — that  is  to  say,  making 
up  medicines,  seeing  that  the  patients  get  them  at 
the  proper  time,  apply  dressings,  bandage  fractured 
limbs,  keep  the  register,  diet  and  prescription 
books,  and  assist  in  compiling  the  monthly  and 
quarterly  returns.  When  a  detachment  is  sent  off 
on  special  service,  the  assistant  surgeon  accompa- 
nies it  as  medical  officer. 

When  epidemics  occur  in  camp,  then  the  duties 
of  the  medical  officers  become  very  arduous;  the 
daily  and  nightly  toil  which  they  are  compelled  to 
undergo,  the  fatigue  of  body  and  anxiety  of  mind 
which  is  their  daily  routine,  soon  breaks  them 
down,  and  many  an  over-zealous  surgeon  becomes 
a  prey  to  the  diseases  which  his  constant  efforts  are 
trying  to  quell  in  others.  This  is  particularly  the 
case  when  typhus  is  raging  in  camp,  when  a  neg- 
lect of  those  hygienic  precautions  which  the  medi- 
cal officers  are  instilling  into  the  men  causes  many 
a  victim  in  the  medical  ranks.  Under  such  condi- 
tions it  becomes  as  imperatively  the  duty  of  the 
suro-eons  to  take  care  of  themselves  as  to  attend  to 
the  sick;  for  should  they  needlessly  sacrifice  their 
lives,  they  entail  severe  suffering  on  their  regiments. 


108  DUTIES   OF    ASSISTANT    SURGEON. 

The  Crimean  surgeons  were  severely  censured,  after 
spending  all  day  in  the  typhus  and  cholera  hospi- 
tals, with  tainted  atmospheres,  for  remaining  there 
during  the  night  also,  when  there  was  no  necessity 
for  it.  It  was  a  useless  and  dangerous  imprudence, 
an  exaggeration  of  duty,  which  deprives  the  army 
of  well-informed  men,  and  impairs  the  utility  of 
the  service. 

In  the  Crimea,  the  surgeons  would  frequently 
meet  together  for  scientific  conference  and  for 
mutual  instruction.  Here  each  gave  his  expe- 
rience and  compared  the  results  of  different 
methods  of  treatment.  Their  meetings  always 
terminated  in  practicing  amputations,  resections, 
and  the  ligation  of  arteries  on  the  dead  subject. 
The  object  of  this  was  not  only  to  gain  dexterity 
in  the  operative  manual,  but  also  to  find  out  who 
were  the  most  skilled  and  therefore  most  worthy 
of  being  intrusted  with  important  duties.  It  is 
said  that  the  mortality  of  the  army  amounted  to 
two  hundred  per  day,  Avhich  gave  ample  material 
for  such  practice.  These  meetings  were  presided 
over  by  one  of  the  highest  staff  surgeons  or  medi- 
cal directors,  who  would  often  deliver  to  the  society 
practical  lectures  upon  the  treatment  of  gunshot 
wounds.  This  plan  might  be  carried  out  in  all 
armies,  as  it  must  redound  to  the  benefit  of  both 
surgeons  and  patients. 


DUTIES    OF    SURGEON    ON    FIELD.  100 

Duties  of  the  Surgeon  on  the  Battle  Field. — 
The  common  fear  which  depresses  the  soldier  on 
the  eve  of  a  battle  more  than  any  other  is  not  so 
much  death,  but  the  dread  of  mutilation.  Bullets 
are  neither  respecters  of  parts  nor  persons,  and 
the  prospect  of  losing  an  eye,  an  arm  or  leg  makes 
many  a  brave  man  quail  before  the  ordeal  through 
which  he  is  to  pass.  So  that  before  a  battle  there 
is  a  vague,  uneasy  restlessness  —  a  foreboding  of 
coming  evil,  which  takes  possession  of  the  bravest, 
and  cannot  be  driven  off  except  by  the  com- 
mencement of  the  fight.  The  early  booming  of 
cannon  braces  all  for  action,  all  thoughts  of  fear 
or  self  are  now  discarded,  the  demon  of  war  rules 
triumphantly  over  the  assembled  host,  and  sup- 
presses, through  thirst  for  blood  and  desire  for 
victory,  all  depressing  influences.  There  is  some- 
thing in  the  smell  of  gunpowder  which  makes 
men  forget  their  origin ;  by  its  magic  wand  women 
are  made  brave,  and  cowards  heroes.  In  the  eager- 
ness of  the  fray,  an  intoxication  guides  all  to  acts 
of  daring.  Who,  in  his  sober  moments,  would 
walk  up  to  the  mouth  of  a  loaded  cannon  to  which 
a  torch  is  being  applied?  Yet  on  the  battle  field 
find  the  man  who,  at  the  word  of  command,  and 
whilst  under  the  stimulating  intoxication  from 
gunpowder,   would  not  face   certain   destruction ! 


110  DUTIES    OF    SURGEON    ON    FIELD. 

Fortunate  it  is  that  Nature  has  so  constituted  us, 
or  the  terror  of  pursuing  what  duty  dictates  would 
be  agonizing  indeed.  The  surgeon  on  the  battle 
field  must  participate  in  the  dangers,  without  the 
stimulation  of  the  conflict ;  he  requires,  therefore, 
a  double  proportion  of  courage  to  sustain  him  in 
the  trying  part  which  he  has  to  perform. 

Upon  the  eve  of  a  battle,  the  regimental  surgeon 
has  much  to  do  to  prepare  facilities  for  the  treat- 
ment of  the  wounded.  He  must  see  that  the  hos- 
pital stores  are  brought  up  with  the  ammunition 
wagons,  as  the  articles  for  treating  the  wounded 
and  saving  the  life  of  comrades  are  fully  as  impor- 
tant as  those  for  the  destruction  of  the  enemy. 
He  examines  his  stores,  and  satisfies  himself  that 
nothing  which  will  be  required  for  the  wounded 
has  been  omitted  or  forgotten.  He  examines  his 
instruments,  his  supply  of  bandages,  lint,  india- 
rubber  cloth  or  oiled  or  waxed  silk,  etc. ;  sees  that 
chloroform  and  opium,  the  main  support  of  the 
wounded,  are  at  hand  in  sufficient  quantity.  Water 
he  has  not  overlooked,  as  an  abundant  supply  will 
be  needed  to  meet  the  incessant,  unmitigated  thirst 
of  the  wounded.  He  should  be  well  supplied  with 
astringents,  of  which  the  per  chloride  or  per  sul- 
phate of  iron  is  the  best,  to  control  annoying 
hemorrhage.     He    should    also   have    a  moderate 


DUTIES    OF    SURGEON    ON    FIELD.  Ill 

supply  of  brandy  to  revive  those  exhausted  from 
hemorrhage,  oil  to  grease  their  wounds,  and  a 
little  tea,  sugar,  and  such  medical  comforts  as  will 
refresh  and  support  the  wounded.  Having  selected 
from  the  general  stock  those  articles  which  he  will 
need,  such  as  all  articles  for  dressing,  as  lint,*  cloth, 
bandages,  oiled  silk,  sponges,  ligatures,  adhesive 
plaster,  splints  for  treating  all  varieties  of  fractures, 
amputating  and  dressing  instruments,  with  medi- 
cines and  stimuli,  and  a  full  supply  of  good  water. 
These  are  carefully  put  upon  a  pack  mule  in  two 
strong  iron-bound  boxes,  called  panniers,  one  hang- 
ing on  either  side  of  the  saddle.  One  is  usually 
devoted  to  medicines,  the  other  is  used  for  dressing- 
apparatus.     This    distribution   gives   the  surgeon 

*  Carded  cutton  has  been  extensively  used  in  military  surgery,  and 
was  found  in  the  Crimea  to  be  a  good  substitute  for  lint  by  the  French 
surgeons,  with  whom  an  abundance  of  lint  is  a  sine  qua  tion  in  the 
treatment  of  wounds.  As  it  can  be  so  easily  obtained  in  any  part  of 
the  Confederate  States,  and  at  so  trifling  a  cost,  it  promises  speedily  to 
usurp  the  place  of  the  officinal  preparation.  Now  that  tents  and  meshes 
are  scarcely  used,  and  receptacles  for  collecting  pus  are  denounced 
in  modern  surgical  practice,  we  see  no  reason  why  carded  cotton,  with 
its  very  soft,  elastic  fibre,  would  not  make  a  more  soothing  dressing 
than  lint,  which  is  often  formed  of  coarse,  hard  threads,  which  would 
leave  their  marks  upon  a  sensitive,  inflamed  surface,  and  therefore  must 
be  the  unrecognized  cause  of  pain. 

Much  can  also  be  said  of  new  cloth  versus  the  old  linen,  of  time- 
honored  reputation.  Suffice  it  to  say,  in  this  connection,  that  an  army 
should  never  clog  its  movements  by  an  excess  of  baggage,  and  that  the 
old  linen  (which  can  be  used  but  once)  required  for  an  army  is  no  small 
item.  New  cloth  can  be  washed  a  dozen  times,  if  required,  which  in 
itself  is  no  mean  recommendation. 


]12  DUTIES    OF    SURGEON    ON    FIELD. 

great  facility  in  moving  about  the  field  where  hi* 
services  may  be  most  required,  whilst  it  dispenses 
with  the  hospital  store  wagon,  which  is. altogether 
too  cumbersome  to  follow  light  troops  in  their 
varied  and  active  movements.  In  European  armies 
every  regiment  has  such  a  pannier,  which  is  con- 
tinually resupplied  from  the  medical  store  wagons. 
The  commanding  general  may  sometimes  have 
good  reasons,  under  particular  circumstances,  for 
ordering  the  medical  wagons  to  remain  behind 
with  the  baggage;  then  the  conveyance  of  all 
needful  medical  supplies  for  the  wounded  on  pack 
horses  becomes  imperative. 

If  the  army  would  adopt  those  regulations  of 
the  Prussian  service,  which  compel  every  soldier 
going  into  battle  to  carry  in  his  knapsack  a  small 
bundle  of  dressings,  prepared  according  to  a  for- 
mula, then  the  hospital  stores  could  in  a  great 
measure  be  dispensed  with,  and  with  few  addi- 
tions to  the  individual  stock,  the  wounded  could 
receive  careful  dressing.  The  instruments  and 
few  medicines  which  the  infirmary  would  require, 
could  then  be  readily  moved  from  place  to  place, 
following  the  line  as  the  din  of  battle  recedes 
from  the  points  where  the  fight  had  commenced. 

The  surgeon  should  examine  the  means  of  trans- 
porting the  wounded  from  where  they  fall  to  the 


DUTIES    OF    SURGEON    ON    FIELD.  113 

field  infirmary:  These  mould  consist  of  at  least 
two  stretchers  for  every  one  hundred  men  en- 
gaged, although  in  European  armies,  four  are  al- 
lowed to  each  company,  besides  light  ambulance 
wagons,  spring  carts,  or  any  other  conveyance  of 
transportation,  to  accommodate  in  the  proportion 
of  forty  persons  for  every  one  thousand  troops. 
The  character  of  the  transport  service  will  depend 
upon  the  character  of  the  country  in  which  the 
war  is  carried  on.  In  a  level  country,  wagons  are 
the  most  serviceable,  whilst  in  hilly  localities,  lit- 
ters carried  b}*  mules  would  be  the  most  comforta- 
ble transportation  for  the  wounded.  In  .European 
armies,  a  distinct  body  of  men  are  employed  for 
conveying  the  wounded,  so  that  practiced  hands 
may  soothe  the  agonies  of  transportation.  This 
is  by  far  the  most  humane  course,  and  as  a  mark 
of  civilized  warfare  should  be  of  universal  adop- 
tion. It  is  highly  important  that  a  similar  body 
be  instructed  to  act  as  nurses  as  well  as  attend 
immediately  upon  the  wounded,  as  this  timely 
assistance  may  save  many  lives  on  the  field.  In 
those  armies  in  which  this  sanitary  corps  has  not 
yet  been  introduced,  the  regimental  quartermas- 
ter in  charge  of  the  pioneers  and  musicians,  form 
a  temporary  body  of  carriers.  Besides  the  litters, 
each  bearer  carries  a  canteen  full  of  water,  and 
10 


114  DUTIES    OF    SURGEON    ON    FIELD. 

the  assistant  surgeon,  who  follows  the  litters  and 
directs  the  transportation,  is  accompanied  by  two 
men  as  orderlies.  One  of  these  orderlies  who 
habitually  follows  the  medical  officer,  whether 
in  battle  or  on  the  march,  carries  the  hospital 
knapsack  which  contains  instruments,  ligatures, 
sponges,  lint,  oiled  silk,  bandages,  tapes,  pins, 
two  field  tourniquets,  a  bottle  of  brandy,  and 
one  of  laudanum  or  morphine,  or  other  medi- 
cines which  may  be  needed  in  an  emergency  on 
the  march  or  in  the  field.  One  of  the  order- 
lies is  armed  to  protect  the  party  against  strag- 
glers and  marauders.  The  surgeon,  for  a  similar 
reason,  should  be  also  armed  with  a  revolver. 
The  orderlies  assist  the  surgeon  in  placing  the 
wounded  carefully  in  the  wagons;' and  also  fol- 
lowing them,  are  at  hand  to  assist  in  unloading 
the  wagons   at  the  field  infirmary. 

When  the  troops  deploy  or  form  for  action,  the 
surgeons,  with  their  assistants  and  pack  horses, 
move  a  short  distance  to  the  rear  out  of  the 
range  of  the  shot,  and  they  establish  their  field 
infirmary.  It  would  be  convenient  if  some  house 
could  be  used  for  this  temporary  hospital. 

"Where  this  cannot  be  had,  the  shade  of  trees 
or  the  shelter  of  a  hill-side  will  answer  the  tem- 
porary  wants   of  the    surgeon.      If  the   body  of 


DUTIES    OF    SURGEON    ON    FIELD.  115 

troops  about  entering  battle  is  a  large  one  with 
an  extended  line,  several  of  these  points  should 
be  selected  and  marked  by  a  suitable  yellow  flag 
which  designates  the  spot  where  those  slight- 
ly wounded  can  seek  surgical  aid.  Instead  of 
each  regimental  surgeon  establishing  such  for  his 
regiment,  it  would  be  much  better  if  they  would 
concentrate  for  individual  assistance,  when  the 
wounded  would  receive  more  attention,  and  the 
work  of  dressing  would  be  much  expedited. 

When  surgeons  combine  at  the  field  infirmaries, 
establish  at  once,  if  possible,  a  division  of  labor ; 
let  there  be  an  understanding  that  those  best 
adapted  by  experience  to  undertake  certain  duties 
should  confine  themselves  strictly  to  the  same. 
When  each  one  knows  what  roll  he  has  to  play, 
and  does  not  interfere  with  others,  a  great  deal 
more  work  can  be  accomplished  than  where  each 
one  acts  independently  for  himself.  The  force  of 
this  will  appear,  when  it  is  remembered  that  all 
experience  shows  the  medical  staff  of  an  army, 
however  numerous,  to  be  always  too  few  on  battle 
days.  Remember  that  all  the  wounded  must  undergo  a 
thorough  examination,  and  all  needful  operations  must 
be  performed  within  twenty-four  hours,  or  the  wound- 
ed suffer  from  neglect.  Now,  take  into  considera- 
tion the  very  small  surgical  staff  of  our  army  and 


116  DUTIES    OF    SURGEON    ON    FIELD. 

the  accuracy  of  fire  of  the  contestants,  with  the 
most  approved  and  destructive  arms  with  very 
long  range,  and  we  will  immediately  see  the  ne- 
cessity of  economizing  time  and  labor. 

The  movements  and  position  of  the  troops  and 
the  character  of  the  ground,  must  establish  the 
necessity  for  the  greater  or  less  concentration  of 
surgeons  at  the  field  infirmaries.  As  the  troops 
advance,  they  are  followed  by  the  bandsmen  or 
bearers  and,  if  the  country  permits  it,  the  ambu- 
lance wagons,  under  charge  of  the  quartermas- 
ter and  assistant  surgeon  with  his  orderlies.  They 
station  themselves  in  the  rear  of  the  advancing 
line,  where  they  can  distinctly  see  what  hap- 
pens, and  remove  immediately,  without  the  range 
of  the  shot,  those  who  may  fall  wounded.  It  is 
imperiousl}'  demanded,  on  the  score  of  humanity, 
that  the  wounded  be  removed  from  the  field  of 
battle  with  as  little  delay  as  possible,  for  early 
treatment.  In  gunshot  wounds,  above  all  others, 
early  surgical  assistance  is  of  the  greatest  moment 
for  success;  and  in  many,  as  in  chest  wounds, 
what  is  omitted  on  the  battle  field  immediately 
after  the  injury  is  received  is  never  made  up,  with 
whatsoever  diligence  and  skill  the  after-treatment 
is  pursued.  Therein  is  the  great  advantage  of  hav- 
ing a  special  transport  corps,  otherwise  the  excite- 


DUTIES   OF    SURGEON    ON    FIELD.  117 

ment  of  battle  or  the  eagerness  of  pursuit  carries 
the  line  to  a  distance  from  the  ground  where  the 
battle  first  commenced;  and  it  is  only  after  the 
victory  is  achieved  that  the  wounded  are  thought 
of  by  their  comrades,  who,  in  scouring  the  field, 
find  many  a  dear  friend  whose  life  has  paid  the 
forfeit  of  delay. 


CHAPTER    V. 

Treatment  of  gunshot  wounds — What  should  be  done 
on  the  field  by  the  assistant  surgeon  in  command  of 
the  litters — The  treatment  at  'the  field  infirmary — 
How  wounds  should  be  examined — The  character 
of  gunshot  wounds — Orifices  of  entrance  and  exit — 
Primary  hemorrhage — Natural  hasmatosis —  Tourni- 
quets but  seldom  required  in  surgery — How  hemor- 
rhage controlled — Examination  of  wound  for  foreign 
bodies  should  only  be  done  once,  but  that  thoroughly 
and  as  soon  as  possible  after  the  accident — The  his- 
tory of  the  case  important — Lodging  foreign  bodies 
always  give  trouble  even  years  after  injury — Gunshot 
wounds  do  not  require  dilatation — Necessity  of  ex- 
amining the  pulsations  of  the  main  artery  below 
the  wound  for  suspected  injury — Ligation  of  the 
open  mouths  of  the  artery  the  rule  of  practice — 
Water-dressing  the  only  rational  treatment  of  gun- 
shot wounds;  its  advantages  over  all  other  applica- 
tions— Secondary  hemorrhage,  how  treated — General 
or  constitutional  treatment  of  gunshot  wounds. 

As  a  soldier  falls  or  is  wounded  in  battle,  lie 
is   at  once  approached  by  the  assistant  surgeon, 


FIELD    SURGERY    WITH    THE    TRANSPORTS.  119 

who  looks  at  his  wounds,  applies  the  hasty 
dressing  which  they  require,  then  placing  him 
comfortably  on  the  litter,  attends  to  his  trans- 
portation. He  can  do  as  much  for  the  wounded 
in  [this  way  as  if  he  were  actively  engaged 
in  operating.  Should  his  injury  permit  him  to 
walk,  a  compress  and  bandage  is  placed  upon 
his  wounds,  if  they  be  severe,  and  he  is  direct- 
ed to  the  field  infirmary.  In  those  with  frac- 
tured limbs,  a  rapid  glance,  quick  intelligence, 
and  an  inventive  turn,  at  once  tells  the  surgeon 
what  is  required  and  suggests  the  means  of 
effecting  it.  With  a  sword-blade,  a  ramrod  or 
a  bayonet,  with  a  handkerchief  or  strip  of  cloth, 
a  fracture  apparatus  is  at  once  improvised,  and  the 
thanks  of  the  wounded,  now  in  comparative  com- 
fort, are  freely  bestowed  during  his  transportation 
to  the  infirmary  or  general  hospital.  If  he  has  a 
mangled  limb,  which  hangs  by  a  very  small  por- 
tion of  the  soft  parts,  the  separation  should  be  at 
once  effected  by  separating  the  dangling  parts 
in  the  mangled  tissues.  Should  he  be  suffering 
much  pain,  which  is  not  usually  the  case,  the 
surgeon  gives  him  a  powder  of  morphine,  with 
which  his  pockets  are  well  stored,  and  at  once 
transports  him  to  the  infirmary,  where  the  proper 
amputation  is  performed.     If  the  wound   be  an 


120  FIELD    SURGERY    WITH    THE    TRANSPORTS. 

abdominal  one,  with  protrusion  of  the  intestines, 
he  sees  whether  the  bowel  is  injured  or  not.  If 
not  injured,  returns  it  carefully  within  the  abdo- 
men, and  gives  a  large  dose  of  morphine  to  ensure 
quiet.  Should  the  intestine  be  cut  by  the  ball, 
he  warns  the  carriers  and  assistants  from  inter- 
fering until  the  wounded  man  be  carefully  trans- 
ported to  the  infirmary.  In  case  of  punctured 
chest  wounds,  with  internal  hemorrhage,  cough- 
ing of  bloody  sputa  and  great  oppression  in  the 
breathing,  the  treatment,  to  be  ultimately  suc- 
cessful, must  commence  at  once.  The  surgeon, 
in  placing  the  wounded  man  in  the  litter,  will, 
if  the  symptoms  be  urgent,  open  a  vein  in  his 
arm  to  save  him  from  immediate  death.  To  this 
timely  bleeding,  on  the  very  spot  where  the  acci- 
dent has  occurred,  and  not  wait  until  transported 
to  a  more  convenient  place,  the  life  of  the  soldier 
often  depends.  Those  wounded  in  the  head,  if 
insensible,  require  very  careful  transportation; 
they  should  be  as  little  disturbed  as  possible. 
Chest  wrounds,  head  wounds,  and  fractured  legs 
give  the  most  trouble,  as  they  require  the  greatest 
care  in  conveying  them  safely  to  the  designated 
places  for  surgical  treatment. 

It  is  seen  from  this  rapid  sketch  that  the  sur- 
geon   who  follows    the    troops    into    action    has 


WASTE    OF    BANDAGES.  1 21 

nothing  to  do  with  amputations,  resections,  ex- 
tracting foreign  bodies,  etc.;  these  form  no  por- 
tion of  his  duties.  His  province  is  solely  to 
prepare  the  -wounded  for  successful  transportation, 
and  beyond  this  he  should  not  intrude  his  atten- 
tions. The  great  perfection  of  rifled  weapons 
have  their  influence  upon  the  duties  of  the  field 
surgeon,  as  the  rapid  and  frequent  changes  of  the 
battle  field  threaten  to  control,  within  very  narrow 
limits,  field  surgery  proper  and  necessitate  very 
hasty  dressing. 

An  emineut  military  surgeon — Air.  Guthrie — 
states  that  bandages,  applied  on  the  field  of  battle, 
are,  in  general,  so  many  things  wasted,  as  they 
become  dirty  and  stiff,  and  are  usually  cut  away 
and  destroyed  without  having  been  really  useful. 
There  is  much  truth  in  this  statement  Much  of 
the  hasty  dressing  by  the  transport  surgeon  can 
very  well  be  dispensed  with.  As  he  has  neither 
the  time,  nor  is  it  his  duty  to  examine  carefully 
the  wounds,  most  of  the  wounded  might  be  sent 
directly  on  to  the  field  infirmary  without  dressing. 
The  dressings,  when  removed  at  the  field  in- 
firmary, are  so  soiled  that  they  are  thrown  away. 
Time,  which  is  so  valuable,  and  also  material, 
which  is  never  in  excess,  but  most  frequently  defi- 
cient, can  be  saved  by  adopting  this  course.     Onlv 

4        ' 
11 


122  EXAMINATION    OF    WOUNDS. 

in  cases  of  sharp  hemorrhage  would  it  be  neces- 
sary to  apply  compresses  and  the  roller  bandage, 
or  what  is  very  rarely  required,  the  tourniquet. 

Should  the  soldier  have  a  large  artery  wounded, 
and  the  hemorrhage  be  excessive,  which  is  but 
eldom  the  case,  the  surgeon  should  instruct  the 
orderly,  who  superintends  his  transportation,  how 
to  make  judicious  finger  pressure.  This  is  much 
better  than  the  tourniquet,  producing  much  less 
engorgement  of  the  injured  tissues. 

Field  surgery,  properly  speaking,  commences  at  the 
field  infirmary.  Here  all  wounds  are  thoroughly 
examined,  and  an  accurate  diagnosis  established. 
The  wTouncls  are  here  thoroughly  cleansed;  all 
foreign  bodies  which  can  be  are  here  removed, 
and  the  first  dressing  made.  If  trivial,  they  are 
dressed  and  the  men  sent  to  rejoin  their  com- 
panies. 

When  the  wounds  are  quite  recent,  before  the 
tissues  become  engorged,  there  is  a  temporary 
absence  of  pain  and  a  relaxation  of  the  injured 
parts,  which  favors  an  examination.  The  wound 
should  now  be  examined  to  its  very  bottom,  to 
detect  the  presence  of  foreign  bodies,  whether 
they  be  balls,  wadding,  portions  of  clothing,  de- 
tached spiculse  of  bone,  etc.  For  this  purpose  the 
finger  is  the  proper  probe,  and  is  used  on  all  occa- 


EXAMINATION    OF    WOUNDS.  123 

sions,  with  rare  exceptions.  It  is  an  intelligent 
instrument,  and,  appreciating  what  it  feels,  it  will 
not  only  discover  the  character  of  foreign  bodies 
complicating  the  canal,  but  wrill  avoid  increasing 
the  dangers  by  making  new  lesions  in  the  depth 
of  the  wound.  In  fresh  gunshot  wounds,  the 
apertures  which  the  balls  now  used  in  warfare 
make,  are  large  enough  to  admit  the  finger  when 
introduced  with  care.  Very  rarely  is  it  necessary 
to  dilate  a  wTound,  with  the  probe-pointed  bis- 
toury, to  assist  in  its  exploration.  The  silver  probe 
is  a  dangerous  and  deceptive  instrument,  and  should 
be  discarded  from  the  battle  field.  Its  use  on  such 
occasions,  for  exploring  recent  wounds,  marks 
the  novice. 

Balls  are  readily  detected  in  a  fresh  wound  by 
placing  the  patient  in  the  position  in  wdiich  he 
received  the  injury,  if  the  direction  from  wdiich 
the  ball  came  be  known.  Portions  of  clothing 
and  wadding  are  detected  with  greater  difficulty. 
Before,  how7ever,  probing  the  wound  for  the  de- 
tection of  foreign  bodies,  be  quite  sure  that  the 
clothing  of  the  soldier  has  been  perforated. 
Often  a  single  orifice  is  seen  leading  into  a  limb 
without  exit,  which  would  at  once  su  freest  an 
embedded  ball;  when  an  examination  of  the 
clothing    would   show  that   the   ball   had   driven 


1-4  EXAMINATION    OF    WOUNDS.   ■ 

these  into  the  wound  without  sufficient  force 
to  transfix  them,  and,  on  removing,  hastily, 
the  clothing,  the  hall  had  heen  extracted  by 
this  diverticulum  pushed  in  before  it.  This  ex- 
amination of  the  clothing  will  save  much  time 
to  the  surgeon,  and  painful,  protracted,  injuri- 
ous probing  to  the  wounded.  "When  the  shirt 
or  drawers  are  not  torn,  no  foreign  body  could 
have  been  lodged  in  the  flesh  which  they  were 
covering.  From  the  nature  of  fresh  wounds,  the 
examination  and  removal  of  all  foreign  bodies 
will  be  more  easily  accomplished  at  an  early 
period,  and  with  less  pain  and  danger  to  the 
wounded;  it  should  be  done  carefully,  thor- 
oughly, and  without  delay. 

A  regular  report  is  kept  of  all  the  cases  dressed 
at  the  field  infirmary,  and  a  brief  description  of 
each  case  is  sent  on  with  the  patient  to  the  gen- 
eral hospital;  so  that  if  proper  officers,  in  whose 
judgment  the  hospital  staff  can  confide,  had  previ- 
ously examined  thoroughly  the  wound  and  sent 
on  their  report,  no  further  examination  is  needed. 
The  pinning  a  card  to  the  coat  of  the  wounded, 
upon  which  is  written  the  history  of  the  wound, 
saves  time,  pain  and  trouble  at  the  regular  hos- 
pital. If  the  surgeon  be  trustworthy,  his  diagnosis 
should  be  respected,  and  no  further  investigation  per- 


EXAMINATION    OF    WOUNDS.  125 

mitted.  Many  serious  cases  can  be  protected  by 
adopting  this  simple  expedient.  In  many  cases 
this  is  the  only  examination  which  the  wound 
will  need.  The  neglect  or  insufficiency  of  the 
first  examination  is  often  the  after-cause  of  the 
loss  of  limb  and  even  life.  After-examinations 
heighten  irritation  and  inflammation  in  the 
wound,  and,  as  they  permit  air  (which  ought 
to  be  rigorously  excluded),  to  pass  to  the  bottom 
of  the  wround,  this  promotes  the  decomposition  of 
the  extravasated  fluids  and  exudations,  induces 
suppuration  and  sloughing,  and  predisposes  to 
pyaemia,  with  its  fatal  sequela?.  Many  a  limb  and 
life  would  be  preserved  if  the  examination  of 
gunshot  wounds  could  be  limited  to  the  battle 
field,  and  military  surgery  will  have  attained 
great  perfection  when  a  thorough  diagnosis  is 
obtained  by  this  first   examination. 

The  extent  and  nature  of  many  gunshot  wounds 
are  often  ascertained  at  a  glance.  Touching  a  limb 
may  be  sufficient  to  indicate  to  the  experienced 
surgeon  the  extent  and  character  of  the  wound  and 
the  appropriate  treatment ;  whilst  other  wounds, 
which  appear  trivial,  as  those  in  the  neighborhood 
of  joints,  may  require  all  the  skill  and  scrutiny 
of  the  most  experienced  to  obtain  a  satisfactory 
diagnosis.     JSTo  haste  should  be  permitted  in  this 


126  TREATMENT    OF    GUNSHOT    WOUNDS. 

examination  to  the  injury  of  the  wounded  through 
carelessness  of  diagnosis.  Should  large  arteries 
be  injured,  they  should  be  ligated  always  in  situ 
above  and  below  the  point  injured,  and  for  this 
purpose  the  wound  must  be  enlarged. 

As  a  general  rule,  torn  tissues  will  reunite, 
whilst  bruised,  crushed  tissues  slough.  All 
wounds  in  which  a  probability  exists  of  union 
by  the  first  intention,  should  be  nicely  adjusted 
by  adhesive  plaster.  The  great  inconvenience  of 
the  ordinary  diachylon  plaster,  which  requires 
heat  to  make  it  adhere,  must  exclude  it  from  field 
service.  The  Husband's,  or  isinglass  plaster,  is 
much  more  easily  applied,  requires  no  heat,  a 
little  moisture  being  all  that  is  needed,  is  not 
injured  by  hot  weather,  and  when  closing  a 
wound  gives  as  much  support  as  the  diachylon. 
It  also  excludes,  completely,  the  air,  with  its  inju- 
rious influences,  which  is  not  its  least  advantage. 

Should  a  limb  be  so  injured  that  joints  are 
largely  opened  into,  main  blood-vessels  and  nerves 
torn  through,  soft  parts  extensively  lacerated,  or  a 
limb  flayed,  then  amputation  should  follow  imme- 
diately the  condemnation  of  the  limb  :  field  sur- 
gery here  proves  itself  the  only  successful  surgery, 
as  all  statistics  clearly  show.  If  the  limb  is  simply 
fractured,  even  if  comminuted  without  injury  to 


NERVOUS    SHOCK.  127 

the  main  blood-vessels  and  nerves,  and  without 
complications  with  joint  injuries,  they  should  be 
considered  simple  fractures,  and  dressed  as  such  at 
the  field  infirmary.  If,  in  connection  with  a  con- 
demned limb  other  mortal  injuries  exist,  the  im- 
propriety of  performing  the  amputation  is  clearly 
seen.  When  joints  are  crushed,  or  the  heads  of 
bones  perforated,  resections  are  urgently  demand- 
ed, and  should  be  performed  before  reaction  takes 
place. 

It  is,  of  course,  understood,  that  although 
wounds  might  be  examined,  foreign  bodies  re- 
moved, and  the  wound,  if  simple,  dressed  whilst 
a  soldier  is  suffering  under  shock,  no  serious 
operation,  which  would  still'  further  depress  the 
nervous  powers  or  cause  a  further  loss  of  blood, 
should  be  performed  until  extreme  depression 
subsides.  Although  the  nervous  shock  accompa- 
nies the  most  serious  wounds,  it  may  often  be  met 
with  in  the  most  trivial  injuries.  It  is  recognized 
by  the  sufferer  becoming  cold,  faint  and  pale, 
with  the  surface  bedewed  with  a  cold  sweat;  the 
pulse  is  small  and  flickering;  there  is  anxiety, 
mental  depression,  with  at  times  incoherence  of 
speech.  Often  this  shock  is  very  transient  when 
accompanying  simple  wounds.  A  drink  of  water 
and  a  few  encouraging  words  may  be  sufficient  to 


128  CHLOROFORM  TO  ALLAY  PAIN. 

dispel  it.  When  it  persists,  even  where  the  in- 
jury appears  trivial,  it  forebodes  trouble;  and  a 
more  careful  examination  may  detect  a  fatal  inju- 
ry. It  is  the  duration,  more  than  the  degree  of 
shock,  which  marks  the  serious  character  of  the 
wound;  and  when  this  constitutional  alarm  per- 
sists, there  is  a  great  fear  that  hidden  mischief  is 
lurking,  and  the  surgeon  should  be  very  guarded 
in  his  opinion  of  the  case.  Keeping  the  patient 
warm,  in  the  recumbent  posture,  with  blankets 
and  hot  bottles,  administering  wine,  brandy,  am- 
monia, hartshorn  to  the  nostrils,  frictions,  and 
cataplasms  to  the  extremities  is  the  course  pur- 
sued to  restore  nervous  energy. 

In  all  painful  operations,  chloroform  should  be 
freely  administered  to  produce  the  desired  anaes- 
thesia. Like  all  valuable  medicinal  agents,  which 
when  taken  in  overdoses  are  poisons,  it  can  re- 
move suffering  or  destroy  life  according  to  its 
administration.  The  dangers  can  be  avoided  by 
never  pushing  its  inhalation  to  stertorous  breath- 
ing; stop  as  soon  as  insensibility  is  attained.  The 
recent  Crimean  and  Italian  wars,  in  recording  the 
advantages  of  chloroform  in  field  surgery,  show  it 
to  be  now  one  of  the  indispensables  for  successful 
practice.  It  saves  the  lives  of  many  wounded, 
who   would  perish   from    the    shock  of  a  second 


TRANSPORTATION    TO    GENERAL    HOSPITAL.  129 

operation,  and  also  many  who  would  Lave  been 
considered  as  without  the  pale  of  surgical  art, 
can  now,  thanks  to  this  invaluable  remedy,  be 
benefited  by  surgery. 

In  our  country,  railroads  traverse  every  portion 
of  the  States,  and  as  battles  usually  occur  in  the 
immediate  neighborhood  of  thoroughfares  be- 
tween large  cities,  it  is  not  improbable  that  they 
will  be  found  in  the  immediate  vicinity  of  battle 
fields.  If  such  be  the  case,  a  sufficient  number  of 
cars  should  be  kept  in  readiness  for  the  use  of  the 
wounded.  Transport  wagons  are  in  constant 
communication  with  the  field  infirmaries.  As  the 
wounded  are  attended  to,  they  should  not  be 
allowed  to  accumulate  around  the  infirmary,  but 
be  sent  off  at  once  to  the  nearest  railroad  station, 
from  whence  they  will  be  distributed  in  the  towns 
nearest  to  the  scene  of  action.  General  hospitals 
should  have  been  previously  prepared  in  these 
localities  for  the  reception  of  the  wounded;  and 
here  the  regular  treatment  commences.  If  it  be 
convenient  for  the  wounded  to  reach  the  general 
hospital  within  twenty-four  hours  from  the  re- 
ception of  their  injuries,  many  serious  cases  for 
operation,  such  as  the  resections,  might  well  be 
deferred  from  the  field  infirmaries  until  the 
wounded  have   arrived  at  the  station  where  that 


130  COMMON    DRESSINGS    FOR    WOUNDS. 

quiet  and  rest,  with  medical  comforts,  which  are 
so  necessary  for  a  successful  result,  can  be  ob- 
tained. When  the  wounded  are  brought  to  the 
field  infirmary,  they  are  not  attended  to  in  the 
order  in  which  they  arrive.  Those  most  seriously 
injured  always  receive  the  earliest  attention,  offi- 
cers and  soldiers  awaiting  their  turn.  If  the 
trivial  accidents  had  been  dressed  upon  the  field, 
they  could  pass  directly  on  toward  the  railroad  or 
the  general  hospital,  without  stopping  at  the  field 
infirmary. 

The  common  dressings  which  all  wounds  receive 
is  a  wet  cloth  covered  with  a  piece  of  oiled  silk 
or  waxed  cloth,  and  secured  with  a  single  turn  of 
the  roll  of  bandage.  This  keeps  the  wound  moist, 
and  is  the  most  soothing,  comfortable,  efficient  and 
simple  dressing  which  can  be  devised.  By  wetting 
the  outer  bandage,  the  cold  produced  by  evapora- 
tion is  transmitted  through  to  the  wound,  whilst 
the  oiled  silk  keeps  the  parts  moist.  When  oiled 
or  india-rubber  cloth  cannot  be  obtained,  and  no 
facilities  exist  for  keeping  the  wound  constantly 
wet,  whilst  the  patient  is  being  transported  to  the 
general  hospital,  a  cloth  well  greased  with  olive 
oil  is  the  best  substitute  for  the  wet  dressings. 
Many  ragged  wounds  may  have  their  edges  paired 
off  and  then  brought  together,  with  every  prospect 


TEMPORARY    HOSPITALS.  131 

of  speech*  union,  provided  the  after  treatment  with 
cold  dressings  is  judiciously  followed. 

It  is  understood  that  all  those  who  can  be  conve- 
niently moved,  should  be  transported  at  the  earliest 
possible  moment  to  general  hospitals,  established 
in  contiguous  towns.  Should  there  be  no  facilities 
for  this  transportation,  then  any  house  in  the 
neighborhood,  contiguous  to  the  battle  field,  must 
be  used  as  a  temporary  hospital  for  the  treatment 
of  those  seriously  wounded,  whose  safety  depends 
upon  absolute  quiet,  rest  and  careful  nursing;  or 
tents  can  be  pitched  for  the  temporary  accommo- 
dation of  the  wounded.  Should  the  army  advance, 
the  regimental  surgeons  must  follow  their  com- 
mands, leaving  either  an  assistant  or  an  extra 
medical  attendant  for  the  wounded,  it  being  pre- 
sumed that  a  reserve  medical  corps  had  been 
attached  to  the  army  for  extra  or  reserved  duty, 
when  it  was  known  at  head-quarters  that  a  battle 
was  expected.  These  reserve  surgeons  will  make 
every  preparation  for  the  comfort  and  accommoda- 
tion of  the  wounded.  Should  the  army  unfortu- 
nately meet  with  a  reverse,  all  available  transport 
must  be  pressed  into  the  service  for  the  removal 
of  the  wounded  to  the  rear,  and  they  must  be  sent 
off  as  speedily  as  possible.  If  this  had  been  at- 
tended to  from  the  commencement  of  the  engage- 


132  SEVERE    WOUNDED    LEFT    TO    ENEMY. 

ment,  there  would  be  fewer  to  move  later  in  the 
day,  when  a  retreat  was  compulsory.  No  wounded 
soldier,  whose  injuries  are  so  slight  that  he  can 
walk,  should  ever  be  carried,  as  he  takes  up  a  place 
in  the  transport  wagon  which  excludes  one  who 
cannot  assist  himself. 

There  are  many  cases  of  injury  to  which  long 
transportation  would  be  certain  death.  If  the 
general  hospital  cannot  be  conveniently  reached, 
such  cases  must  be  treated  at  some  farm-house 
contiguous  to  the  field  of  battle  ;  and  if  troops 
are  compelled  to  retreat,  humanity  dictates  that 
the  severely  wounded  should  always  be  left  to  the 
enemy,  with  a  sufficient  number  of  competent  sur- 
geons to  look  after  their  wants.  When  left  with- 
out surgeons,  they  are  always  neglected,  and  many 
lives  may  be  sacrificed  for  want  of  that  immediate 
attention  which  the  enemy's  surgeons  must  first 
give  to  their  own  wounded,  and  which  precious 
time  can  never  be  recovered.  This  becomes  espe- 
cially urgent  where  the  nations  at  war  speak  dif- 
ferent languages.  The  rule  now  recognized  in 
civilized  warfare  is,  always  to  leave  competent 
surgeons  with  the  wounded  who  are  left  to  be 
cared  for  by  the  enemy. 

Appearance   of  Gunshot    Wounds. — We  have 


APPEARANCE    OF    GUNSHOT    WOUNDS.  133 

already  stated  that  the  more  perfect  and  destruc- 
tive arms  now  in  use  in  modern  warfare,  and  the 
variety,  form  and  size  of  missiles,  have  modified 
materially  the  symptoms  and  march  of  gunshot 
wounds.  The  conical  shot,  with  its  excessive 
momentum,  transfixes  the  tissues  with  great  ra- 
pidity, and  when  only  soft  parts  are  involved,  the 
crushing  and  bruising  is  by  no  means  so  exten- 
sive as  with  round  ball.  The  entrance  made  by 
a  conical  ball  in  the  skin  is  oval  and  sometimes 
even  linear,  as  if  made  by  the  point  of  a  sabre. 
Usually,  they  pass  directly  through  the  soft  parts, 
rarely  burying  themselves,  and,  when  not  impeded 
in  their  transit,  there  is  but  little  difference  be- 
tween the  two  orifices  of  entrance  and  exit. 
When  the  conical  ball,  entering  point  foremost, 
and  meeting  some  resistance  in  its  course  through 
the  tissues,  is  either  changed  in  form  or  is  turned 
upon  its  side,  the  orifice  of  exit  is  found  very 
large,  irregularly  torn,  with  the  surrounding  tissues 
much  bruised. 

Round  balls  usually  give  an  entrance  sur- 
rounded by  blackened,  inverted  tissues;  these 
having  been  evidently  mashed  or  crushed  by  the 
ball  prior  to  its  entrance.  The  orifice  of  exit  is 
usually  more  or  less  everted  and  lacerated.  These 
two  orifices  are,  however,  modified  in  appearance 


134  APPEARANCE    OF    GUNSHOT    WOUNDS. 

by  so  many  circumstances  —  the  form,  size, 
velocity  and  number  of  the  missiles;  changes  in 
the  missile  after  its  entrance  into  the  bod}T  and 
prior  to  its  escape ;  the  distance  of  the  wounded 
party,  his  position,  his  clothing,  foreign  bodies 
which  may  have  been  about  his  person,  and  driven 
before  the  ball,  etc. — that  in  some  cases,  without 
the  history  of  the  accident  from  the  patient  or 
those  wdio  saw  the  occurrence,  it  would  be  diffi- 
cult to  determine  which  opening  was  first  made. 
The  effects  produced  by  the  action  of  the  ball 
upon  the  twro  orifices  can  he  easily  understood 
when  it  is  remembered  that  in  entering,  the 
tissues,  which  are  being  perforated,  are  support- 
ed by  the  entire  thickness  of  limb,  so  that  often 
the  ball  carries  before  it  a  piece  of  flesh  which 
it  has  cut  out  as  by  a  die,  and  hence  the  more  or 
less  rounded  appearance  of  this  opening ;  whilst 
after  traversing  the  limb  in  making  its  exit,  the 
tissues  through  which  it  is  now  pushing  have  no 
support,  they  are  stretched  inordinately  before 
they  are  torn,  hence  the  flap-like  lacerations  of 
this  exit,  with  sometimes  nothing  more  than 
a  rent  or  split  in  the  skin.  All  who  are 
familiar  with  the  driving  of  a  nail  through 
a  board  or  firing  at  the  same  with  a  pistol, 
will     see    a    rough    working    of    this    principle. 


APPEARANCE    OF    GUNSHOT    WOUNDS.  135 

These  peculiarities  are  said  to  be  so  stamped 
upon  the  clothing,  that  often,  by  an  examina- 
tion of  them  alone,  a  diagnosis  can  be  es- 
tablished. 

It  is  often  of  consequence  to  determine  the 
character  of  these  apertures,  so  as  to  distin- 
guish between  a  traversed  ball,  with  its  two 
orifices,  or  two  balls  embedded.  At  the  same 
time  it  must  not  be  forgotten  that  one  ball  may 
make  several  openings,  by  the  ball  being  divided 
in  the  limb  upon  a  sharp  crest  of  bone.  Such 
cases  are  not  unusual  where  the  round  musket 
ball  strikes.  A  half  of  the  ball  may  pass  out,  a 
portion  remaining  behind.  A  single  ball,  by  split- 
ting in  this  way  against  some  obstacle  in  the  fiesh, 
has  been  known  to  break  into  six  pieces,  each  in 
exit  making  a  corresponding  wound. 

Conical  balls  show  much  less  deviation  than 
round  balls.  They  usually  follow  a  straight  course, 
ploughing  through  all  opposing  structures :  noth- 
ing resists  the  penetrating  force  of  these  projec- 
tiles. They  seldom  follow  the  contour  of  bones, 
as  do  often  the  round,  but  at  once  crush  them; 
their  double  wTeight  and  increased  velocity  making 
many  more  fractures  than  the  round  ball  of  for- 
mer wars. 

In  spite    of  the  rapid  passage  of  even  conical 


136  APPEARANCE    OF    GUNSHOT    WOtJNDS. 

balls,  some  of  the  tissues,  through  their  toughness 
and  elasticity,  escape  direct  injury  from  them. 
Arteries  come  under  this  head.  Owing  to  their 
peculiar  structure,  cylindrical  form  and  loose 
connections,  lying  on  a  bed  of  very  loose  cellu- 
lar tissue,  which  permits  of  considerable  move- 
ment, they  often  escape  transfixion,  when  their 
position  lies  evidently  in  the  direct  course  of 
the  ball.  From  the  battle  fields  of  Italy,  I  saw 
several  of  the  wounded  in  the  hospitals  at  Mi- 
lan, who  had  received  such  injuries  about  the 
root  of  the  neck,  where  balls  had  traversed  in 
some  cases,  antero-posteriorily,  in  others  later- 
ally, going  deeply  through  the  soft  parts,  yet 
picking  their  wa}T,  as  it  were  with  such  care,  as 
to  avoid  the  great  vessels  among  which  the  mis- 
sile had  channeled  its  course.  So  great  is  this 
power  of  avoiding  perforation  in  the  large  arte- 
ries, that  rarely  does  death  take  place  on  the 
battle  field  from  division  bf  the  large  ves- 
sels of  the  extremities  by  bullets.  When  a  ball 
strikes  a  limb  fairly,  at  right  angles,  it  produces 
the  least  injury  to  the  tissue  which  it  traverses; 
it  forms  a  simple  canal,  which  might  heal  with 
very  little  suppuration  or  sloughing:  but  when 
it  strikes  at  an  angle,  particularly  when  the  ball 
has  lost  a  part  of  its  momentum,  it  ploughs  up 


NERVOUS    SHOCK.  137 

the   tissues  frightfully,  and  extensive  destruction 
follows. 

Although  cases  are  upon  record  where  gun- 
shot wounds  have  healed  by  the  first  intention, 
the  surgeon  must  not  look  for  such  a  happy 
result.  With  but  rare  exceptions,  suppuration 
is  the  rule,  and  he  must  be  prepared  to  con- 
trol its  action,  and  the  excessive  reaction  which, 
in    most   cases,   would  accompany  it. 

A  certain  amount  of  hemorrhage  always  ac- 
companies gunshot  wounds;  but  owing  to  the 
irregularity  and  the  asperities  of  the  sides  of 
the  wound  favoring  the  clotting  of  blood,  we 
usually  find  that  the  external  escape  soon  ceases, 
whilst  internal  hemorrhage,  to  a  limited  extent, 
extravasates  into  the  surrounding  tissues.  When 
the  divided  blood-vessels  are  so  closed  that  the 
blood-cells  can  no  longer  escape,  serous  oozing 
still  goes  on  infiltrating  the  tissues.  These  are 
the  causes  of  the  rapid  swelling  which  follows 
gunshot  wounds. 

The  pain  which  accompanies  the  reception 
of  gunshot  injuries  is  often  so  trivial,  that  the 
attention  of  the  wounded  is  only  called  to  the 
fact  by  blood  streaming  down  his  legs.  The 
majority  liken  the  striking  of  a  ball  to  a  smart 
blow  with  a  supple  walking  cane,  whilst  with  a 
12 


18S  NERVOUS    SHOCK. 

few  the  pain  is  very  severe,  and  simulates  the 
feeling  which  would  be  produced  by  running 
a  red-hot  wire  through  the  flesh.  McLeod 
mentions  the  case  of  an  officer  who  had  both 
of  his  legs  carried  away,  and  who  only  became 
aware  of  the  injury  which  he  had  received  when 
he  attempted  to  rise. 

It  appears  as  if  every  gunshot  wound  was 
accompanied  by  a  certain  amount  of  shock,  or 
a  partial  paralysis  of  sensation,  which  is  nature's 
preparation,  permitting  a  thorough  examination, 
with  little  or  no  pain.  The  unusual  quiet  of 
a  hospital  the  night  following  a  battle  has  been 
repeatedly  noticed,  and  is  accounted  for  by  this 
nervous  shock.  When  this  condition  passes  off", 
then  reaction  brings  with  it  much  suffering. 
In  this  nervous  shock,  with  the  suspension  of 
activity  in  the  circulatory  function,  lies  the 
safety  of  many  a  wounded  soldier.  Its  influ- 
ence is  immediately  felt  in  the  injured  tissues, 
and  the  infiltration  and  engorgement  of  these 
are  prevented.  When  nervous  depression  exists, 
but  little  blood  escapes  from  the  injured  vessels, 
and  as  there  is  no  force  from  behind,  owing  to 
the  diminished  action  of  the  heart,  to  drive  on 
and  keep  in  motion  this  blood,  its  clotting  is 
favored.     When   reaction    ensues,   the   clot   is  al- 


HEMORRHAGE,    HOW    CHECKED. 


130 


ready  so  firmly  established  that  it  cannot  be  dis- 
placed; the  injured  vessels  remain  thoroughly  and 
permanently  plugged  up,  and  the  dangers  from 
immediate  hemorrhage  are  prevented. 

As  the  wounded  soldier  is  always  clamorous 
of  having  his  injuries  attended  to  as  early  as  pos- 
sible, and  as  experience  teaches,  that  all  wounds, 
and  above  all  others  gunshot  wounds,  are  benefited 
by  immediate  dressing,  they  should  be  attended 
to  on  the  field  of  battle  ;  then  they  give  less 
trouble  to  the  surgeon,  less  pain  to  the  soldier, 
and  much  better  final  results  in  treatment. 
Here  all  hasty  dressings  or  examinations  are  to 
be  deprecated,  and  a  methodical  course  pursued. 
The  indications  of  treatment,  in  all  gunshot 
wounds,  are,  1st,  To  control  hemorrhage;  2d,  To 
cleanse  the  wound  by  removing  all  foreign 
bodies,  and,  3d,  To  apply  such  dressings  and 
pursue  such  a  rational  course  of  treatment  as 
will   establish   rapid  cicatrization. 

Hemorrhage,  which  produces  such  terror  in  the 
bystanders  and  anxiety  in  the  patient,  should 
never  unnerve  the  surgeon,  who  requires  all  of  his 
self-possession  and  surgical  tact  to  cope  success- 
fully with  this  ebbing  away  of  life.  Fortunately, 
in  gunshot  wounds,  serious  hemorrhage  is  of  rare 
occurrence;  and  when  the  largest  arteries  are  in- 


14:0  TOURNIQUETS    DISCARDED. 

jnred,  they  either  cease  bleeding  spontaneously, 
or  the  patient  dies  so  rapidly,  that  art  is  of  little 
ayail.  If  the  case  is  not  injuriously  interfered 
with,  the  natural  hemostatics  soon  controls  the 
bleeding.  The  ragged  character  of  the  wound, 
and  the  nervous  shock  accompanying  the  injury, 
or  brought  on  by  the  loss  of  blood,  reacting  upon 
the  circulatory  organs,  so  diminishes  the  heart's 
impulse  and  drives  so  little  blood  to  the  extremi- 
ties, as  to  favor  a  stagnation  of  blood  in  the 
wound.  The  formation  of  a  clot  plugs  up  the 
orifice  in  a  bleeding  vessel,  and  stops  any  further 
loss  of  blood. 

This  spontaneous  arrest  of  hemorrhage  is  usually 
permanent;  and  if  the  ordinary  prophylactic 
course  is  pursued  of  absolute  rest  and  quiet, 
with  the  limb  elevated  and  bandaged,  no  return 
shows  itself.  Should,  on  the  contrary,  meddle- 
some surgery  suggest  the  use  of  a  tourniquet, 
which  cuts  off  the  circulation  and  especially  the 
veinous  return,  the  limb  soon  swells,  tissues 
become  engorged,  excessive  extravasation  in  the 
wound  follows,  and  a  train  is  laid  for  future  mis- 
chief. The  field  tourniquet,  in  former  days,  was 
so  much  in  vogue  that  it  was  considered  indis- 
pensable on  the  battle  field,  and  was  therefore 
carried  in  large  numbers,  to  be  applied  to  every 


HEMORRHAGE,    HOW    CHECKED.  141 

limb  from  which  blood  was  trickling,  or  from 
which  hemorrhage  was  feared.  Now,  they  are 
nearly  discarded  from  field  service,  and  recent 
experience  recommends  their  abolition  from  the 
field,  as  doing  more  harm  than  good  to  the 
wounded.  Unless  very  tightly  applied,  it  is  of  no 
service,  as  it  does  not  control  the  bleeding,  and  if 
firmly  applied  it  acts  as  a  general  ligature  around 
the  extremity,  and  can  be  used  but  for  a  short 
time  without  injury  to  the  limb. 

Recent  writers  warn  surgeons  of  the  too  hasty 
use  of  hemostatics,  and  suggest  that  it  is  better 
for  the  wounded  to  lose  a  little  blood,  which  will 
diminish  the  heart's  propulsive  force,  than  have 
the  wounded  tissues  filled  with  extravasated 
blood.  If  the  hemorrhage  be  free,  immediately 
after  the  receipt  of  injury,  the  best  mode  of  con- 
trolling it  would  be  the  application  of  a  ball  of 
lint,  a  compress,  or  sponge  over  the  wound,  secured 
by  a  bandage,  which,  in  closing  the  outer  orifice, 
favors  the  formation  of  a  clot.  If  the  hemor- 
rhage is  at  all  active,  as  if  from  some  large  artery, 
in  addition  to  the  compress  on  the  wound,  the 
entire  limb  should  be  carefully  enveloped  in  a 
bandage,  to  some  distance  above  the  injury,  so 
that  by  compressing  the  soft  parts  it  could  dimin- 
ish the  amount  of  circulating  fluid  in  the  limb, 


142  HEMORRHAGE,    HOW    CHECKED. 

and  prevent  the  ingress  of  blood  into  the  tissues. 
The  hemostatic  properties  of  this  dressing  can 
be  increased  by  soaking  the  sponge  or  compress 
covering  the  wound  with  the  per  chloride  or  per 
sulphate  of  iron,  which,  as  a  powerful  astringent, 
when  coming  in  contact  with  fresh  blood,  will 
immediately  form  a  clot.  A  lump  of  ice  placed 
upon  the  compress  will  act  with  equal  efficiency. 
A  sponge  or  compress,  with  or  without  the  iron 
styptic,  tied  on  the  bleeding  wound,  is  all  that 
the  surgeon  superintending  the  transportation  of 
the  wounded  is  expected  to  do.  Unless  the  hem- 
orrhage is  very  violent,  threatening  immediate 
destruction  of  life,  the  tourniquet  is  rarely  re- 
quired. All  recent  writers  on  military  surgery 
recommend  that  field  tourniquets  be  dispensed 
with,  as  they  are  generally  a  useless,  and  often 
when  carelessly  used,  a  dangerous  instrument. 
The  finger  pressure  of  an  intelligent,  assistant  is 
better  than  any  tourniquet  ever  made,  and  is  a  far 
preferable  means  of  controlling  excessive  hemor- 
rhage, which  the  compress  and  bandage  may  fail  to 
check.  The  femoral  artery,  for  any  injury  to  its 
trunk  or  large  branches,  should  be  compressed  in 
the  groin  where  it  runs  over  the  pubic  bone ;  the 
brachial,  where  it  pulsates  against  the  head  of  the 
humerus,  as  here  its  course  is  nearly  subcutaneous. 


PROBING    WOUNDS.  143 

When  the  position  of  these  main  trunks  are 
shown  to  any  intelligent  assistant,  and  he  is  made 
to  recognize  the  throbbing  of  the  artery,  he  will 
have  no  difficulty  in  keeping  the  vessel  com- 
pressed during  the  transportation. 

As  soon  as  the  wounded  arrives  at  the  tempo- 
rary resting  place  where  the  surgeons  are  assem- 
bled, all  bandages  are  removed,  and  the  wound 
carefully  examined.  A  glance  at  the  wound 
when  the  clothing  has  beeu  previously  examined, 
will  often  tell  when  there  are  two  orifices  differ- 
ing in  appearance  and  in  a  direct  line  with  each 
other,  whether  foreign  bodies  have  lodged  or  not. 
As  the  patient  is  now  faint  from  loss  of  blood 
and  from  nervous  depression,  the  wound  not  yet 
being  painful  or  swollen,  the  surgeon  using  his  fin- 
ger, which  is  the  only  admissible  probe  on  such  occa- 
sions that  the  military  surgeon  of  experience  recognizes, 
examines  the  entire  extent  of  the  wound,  search- 
ing for  foreign  bodies. 

This  examination  is  made  without  fear  of  repro- 
ducing hemorrhage,  as  the  finger  cannot  displace 
the  clots  which  hold  firmly  to  the  openings  in  the 
vessels.  Every  surgeon  has  .noticed  how  rudely 
a  stump  might  be  sponged,  and  what  force  it 
requires  to  wipe  away  clots  which  have  formed 
over  the  face  of  a  smooth,  incised,  open  wound. 


144  PROBING    WOUNDS. 

The  adhesions  are  increased  a  hundred-fold  by 
the  irregularities  of  a  concealed  bullet  track. 
The  finger  finds  no  difficulty  in  entering  a  hole 
through  which  a  bullet  has  passed,  if  examined, 
as  every  wound  should  be,  before  swelling  has 
taken  place. 

A  silver  probe  will  travel  in  the  direction 
given  to  it  by  the  surgeon,  in  examining  fresh 
wounds,  and  as  most  jiwsons  guide  the  ■probe  in- 
stead of  allowing  the  probe  to  guide  them,  the  true 
course  of  a  ball  can  only  be  determined  by  it 
with  great  difficulty.  It  is  but  recently  that 
I  saw  a  physician  of  experience,  in  seeking  the 
course  of  a  ball  which  had  lodged  in  the  thigh, 
apparently  without  effort,  pass  the  probe  among 
the  muscles  quite  across  the  limb;  so  that,  the 
bullet  wound  being  on  the  outer  side  of  the  thigh, 
the  end  of  the  probe  could  be  felt  under  the  skin 
on  its  inner  side.  When  the  finger  was  intro- 
duced it  followed  the  track  of  the  ball  at  a  very 
oblique  course  from  the  one  which  the  probe  had 
taken.  This  example  is  sufficient  to  show  why 
military  surgeons  denounce  the  silver  probe,  and 
distinguish  by  its  use  the  tyro  in  surgical  practice. 

The  wound  is  examined  from  both  sides,  with 
the  double  object  of  finding  foreign  bodies  which 
may  have  lodged,  and  seeing  the  proximity  of  the 


REMOVE    FOREIGN    BODIES.  145 

course  of  the  ball  to  the  main  arteries  of  the 
limb.  It  is  a  matter  of  great  importance  to  deter- 
mine the  condition  of  large  vessels,  whether  they 
be  injured  or  not,  by  examining  the  degree  of 
pulsation  which  they  possess :  as  an  injury  would 
necessitate  a  very  careful  after-treatment  to  avoid 
secon dary  hemorrhage. 

Should  but  one  opening  exist,  and  all  the 
clothes  of  the  soldier  covering  the  wound  be 
torn,  the-  probability  is,  that  foreign  bodies  com- 
plicate the  wound.  It  must  be  remembered  that 
the  ball  as  a  hard  body  can  usually  be  readily 
recognized,  but  that  portions  of  wadding  or 
clothing  may  be  readily  mistaken  for  a  clot  of 
blood  or  the  ragged  lining  of  the  wound.  This  is 
particularly  the  case  when  they  become  satura- 
ted with  the  secretions.  Forewarned  being  fore- 
armed, the  surgeon,  remembering  these  difficul- 
ties, will  examine  with  special  care  for  these  soft, 
foreign  complications.  When  found  they  should 
be  extracted,  as  their  presence  is  certain  to  estab- 
lish a  high  degree  of  inflammatory  excitement, 
with  profuse  subsequent  suppuration. 

This  effect  was  well  shown  in  the  case  of  a  pri- 
vate of  the  2d  Regiment  of  South  Carolina  Vol- 
unteers, who,  during  the  attack  on  Fort  Sumter, 
was  shot  by  the  accidental  discharge  of  a  musket. 
13 


146  HISTORY    OF    CASE    IMPORTANT. 

The  ball  entered  the  chest  at  the  anterior  fold  of  the 
armpit,  fractured  the  clavicle,  and  after  a  course  of 
nearly  six  inches,  was  stopped  by  the  tough  skin 
over  the  posterior  portion  of  the  shoulder.  The 
ball  was  readily  detected  by  the  regimental  sur- 
geon, and,  by  an  incision  through  the  skin,  was 
easily  removed.  Inflammation  of  a  high  grade 
followed.  He  was  sent  up  to  a  city  hospital  one 
week  after  the  accident,  when  he  was  losing  from 
three  to  four  ounces  of  pus  daily  from  the  wound. 
O.n  the  day  after  his  admission,  in  examining  the 
wound,  I  detected  in  the  shoulder  wound  some 
substance  resembling  a  slough,  and  upon  extract- 
ing it,  found  a  mass  of  wadding  over  two  inches 
long  and  as  thick  as  the  finger,  which  tent-like 
mass  had  been  driven  into  the  tissues  by  the  ball. 
Examination  of  his  clothing  now,  for  the  first 
time,  showed  the  deficiency  in  the  lining  of  his 
coat  from  which  this  mass  had  been  torn.  The  re- 
moval of  this  irritant  diminished  the  discharge 
immediately,  so  that,  in  the  succeeding  twenty-four 
hours,  the  discharge  diminished  to  one-sixth  its 
former  quantity,  and  in  four  days  was  hardly  suffi- 
cient to  soil  the  dressing. 

The  history  of  the  case  is  of  much  import- 
ance in  examining  wounds.  Often,  the  course  of 
the  ball  cannot  be  discovered  without  it.     What 


HISTORY    OF    CASK    IMPORTANT.  147 

surgeon,  however  great  his  experience,  seeing 
a  wound  made  in  the  arm  by  a  ball,  would 
think  of  looking  in  the  opposite  thigh  for  its 
place  of  lodgment,  did  he  not  learn  that  the 
injury  was  received  from  above,  whilst  mount- 
ing a  scaling-ladder,  with  arms  raised  above  the 
patient's  head?  The  ball  entering  the  back  of 
the  arm  near  the  elbow,  passed  down  the  arm 
under  the  shoulder-blade,  across  the  loin  and, 
traversing  the  buttock,  lodged  under  the  skin 
of  the  outer  part  of  the  opposite  thigh,  where 
it  was  found,  and  removed.  Knowing  the  direc- 
tion from  whence  the  ball  came,  and  the  position 
in  which  the  soldier  was  placed,  you  know  at 
once  the  course  which  the  ball  most  probably 
took ;  and  your  examinations  in  that  direction 
will  not  only  save  much  time,  but  save  the  pa- 
tient much  suffering  and  annoyance.  Often,  the 
play  of  a  muscle  will  shut  off  the  track  of  the 
ball.  The  relations  of  the  soft  parts  vary  with 
every  position  of  the  limb,  and  a  passage  made 
when  a  limb  was  flexed,  could  not  be  followed 
when  the  same  limb  is  extended.  Hence  the 
necessity  of  placing  the  limb  in  the  same  posi- 
tion in  which  it  was  when  the  injury  was  re- 
ceived. 

The    wound    having    been   carefully    examined 


148  REMOVAL    OF    FOREIGN    BODIES. 

by  the  linger  within  and  careful  manipulations 
without,  and  the  foreign  body  detected,  it  should 
be  at  once  removed.  This  rule  may  nearly  be 
considered  absolute,  as  all  military  surgeons  place 
great  weight  upon  its  accomplishment.  The  ques- 
tion is  not  so  much  whether  balls  can  remain 
innocuous  in  the  flesh,  but  do  they  ?  Those  who 
have  had  experience  in  gunshot  wounds  in  the 
Held,  know  Iioav  excessive  is  the  irritability  caused 
by  the  presence  of  a  ball  in  a  wound;  how  restless 
and  irritable  the  patient  is  until  it  is  removed; 
how  profuse  the  suppuration  and  prolonged  the 
period  of  treatment  in  those  cases  in  which  it 
has  been  left:  and  how  frequently  the  after-conse- 
quences are  so  distressing,  the  pain  so  perma- 
nent, and  discharge  so  constant,  as  to  demand 
future  interference  or  make  life  a  burden.  If 
such  be  the  case  with  ball,  how  much  the  more 
urgent  the  extraction  of  the  foreign  bodies  is 
indicated,  especially  fragments  of  shell,  portions 
of  clothing,   etc. 

Balls  may,  in  time,  become  encysted,  but 
these  are  exceptional  cases  :  and  even  when 
such  occur,  their  presence  in  after  years  may 
set  up  inflammation,  which  will  mat  together  and 
bind  down  important  parts,  whose  usefulness 
depends    upon    freedom    of    motion.       Repeated 


REMOVAL    OF    FOREIGN    BODIES.  149 

abscesses  may  form,  pressure  upon  bones  may 
give  rise  to  ulceration  and  a  tedious  exfoliation, 
blood-vessels  may  ulcerate,  nerves  be  painfully 
compressed,  and  life  rendered  miserable,  if  not 
jeopardized. 

In  McLeod's  Surgery  of  the  Crimea,  the  report 
of  M.  Hutin,  chief  surgeon  of  the  Hotel  des 
Invalides,  is  given,  which  is  a  striking  commen- 
tary  in  favor  of  the  removal  of  all  foreign  bodies. 
He  reports  that  of  4,000  cases  examined  by  him, 
in  which  balls  had  remained  unremoved,  only 
twelve  men  suffered  no  inconvenience ;  and  the 
wounds  of  two  hundred  continued  to  open  and 
close  continually  till  the  foreign  body  was  re- 
moved. 

If  the  ball  be  felt  loose  in  the  soft  parts,  a  bul- 
let forceps  can  be  made  to  seize  it;  and  it  can  be 
extracted  without  difficulty,  provided  the  disengaged 
hand  of  the  surgeon  support  the  limb  on  the  oppo- 
site side  to  that  at  which,  the  forceps  is  introduced. 
Otherwise  the  ball  glides  in  front  of  the  forceps 
and  cannot  be  seized.  The  ordinary  bullet  forceps, 
as  simulating  the  dressing  forceps  of  the  pocket 
case,  was  the  instrument  preferred  by  Larrey, 
and  is  still,  deservedly,  in  general  use.  Many 
changes  have  been  made  in  these,  without  ad- 
vancing to  anv   extent   the    merits  of  the    instru- 


150  REMOVAL    OF    FOREIGN    BODIES. 

merit.  A  very  good  bullet  forceps  is  one  ter- 
minating with  a  sharp  prong  on  either  blade,  at 
right  angles  to  the  blade,  so  that  when  closed 
the  points  are  protected  by  the  blades.  These 
act  as  an  axis  upon  which  the  ball  may  be 
rolled  out  of  the  wound,  instead  of  being  drawn 
out  as  with  the  dressing  forceps. 

When  a  ball  is  firmly  imbedded  in  bone,  it  is 
removed  by  boring  into  it  with  a  gimlet,  which 
holds  it  securely  and  permits  sufficient  force 
being  used  for  dislodging  it,  or  it  may  be  cut  out 
by  using  a  trephine.  Should  a  ball  have  trav- 
ersed a  limb,  as  it  often  does,  and  its  escape  be 
resisted  by  the  tough,  elastic  skin  which  very 
often  successfully  impedes  the  further  progress  of 
the  ball,  it  should  be  removed  by  making  an  in- 
cision over  its  position,  and  not  be  sought  and 
drawn  through  the  entire  length  of  track  which 
it  had  traversed. 

Baudens,  in  noting  the  difficulty  of  extracting 
these  subcutaneous  balls,  ascribes  it  to  a  layer 
of  cellular  tissue,  which  firmly  and  completely 
caps  the  ball.  It  is  thin  enough  to  be  diaphinous, 
and  yet  tough  enough  to  clasp  and  hold  firmly  the 
bullet.  Guthrie  speaks  of  the  difficulties  of  ex- 
traction depending  upon  the  surgeon  being  too 
fearful  of  increasing  the  incision.    Balls  can  be  ex- 


REMOVAL    OF    FOREIGN    BODIES.  151 

tracted  with  the  least  pain  and  with  great  rapidity 
by  making  a  bold  incision.  This  course  marks 
the  difference  between  civil  and  military  surgery; 
half  an  inch  added  to  the  incision  does  not  in- 
crease its  dangers,  and  expedites  the  extraction. 
Be  quite  sure,  however,  that  you  are  cutting  upon 
a  ball  and  not  upon  some  bony  prominence, 
which  comparison  with  the  opposite  limb  should 
warn  you  from.  It  is  sufficient  to  mention  that 
such  mistakes  have  happened  to  military  sur- 
geons. 

By  foreign  bodies  we  mean  balls,  pieces  of 
clothing,  spicule  of  bone,  which  have  been  bro- 
ken off  and  are  loose  in  the  wound,  and  any 
articles  about  the  person  which  may  have  been 
driven  before  the  hall.  These  should  all  be  re- 
moved immediately  after  the  injury  has  been  re- 
ceived, and  before  swelling  or  infiltration  renders 
the  task  difficult.  When  done  early,  the  wound 
will  be  found  sufficiently  large  to  allow  of  the 
easv  extraction  without  dilating.  It  is  onlv  when 
this  early  attention  is  neglected,  and  the  wound 
has  closed  by  inflammatory  effusions,  that  the 
removal  is  painful  and  difficult,  requiring,  in 
some  instances,  the  use  of  the  knife  to  enlarge 
the    passage. 

The  dilatation   of  gunshot  wounds,  which  was 


152  REMOVAL    OF    FOREIGN    BODIES. 

formerly  the  constant  rule  of  practice,  is  now 
altogether  rejected  from  military  surgery,  unless 
it  be  for  the  special  purpose  of  ligating  a  bleed- 
ing artery,  or  extracting  a  foreign  body  which, 
from  changes  in  the  wound,  cannot  be  readily  ex- 
tracted without  injury  to  the  soft  parts.  This 
old  medical  dogma  was  based  neither  upon  ex- 
perience nor  observation,  and  is  now  very  prop- 
erly considered  useless,  injurious  and  barbarous. 
When  a  ball  alone  complicates  a  wound,  if  it  be 
not  readily  found,  after  a  careful  and  intelligent 
search,  rather  than  continue  the  examination  from 
day  to  day,  which  can  only  be  prejudicial  to  the 
case,  from  the  irritation  and  inflammation  which 
will  be  excited,  it  would  save  the  surgeon  much 
anxiety  and  the  patient  much  annoyance,  if  the 
ball  or  other  foreign  body  be  left  until  suppuration 
be  well  established.  Then  it  will  gradually  ex- 
pose its  situation,  and  can  be  much  more  readily 
removed  than  during  the  height  of  reaction 
when  the  parts  are  very  much  swollen  and  very 
painful.  The  surgeon  will  assist  nature  in  the 
expulsion  as"  soon  as  the  swelling  has  subsided 
to  such  an  extent  that  the  finger  or  instrument 
can  again  be  introduced  into  the  wound. 

The    above    rules    apply    chiefly    to    gunshot 
wounds  of  the  extremities;  those  of  the  trunk  and 


PRIMARY    EEMORRHAGE.  153 

liead  offer  so  many  exceptions  to  the  above,  and 
require,  in  a  measure,  such  special  treatment, 
that  the  course  to  he  pursued  in  these  wounds, 
complicated  with  foreign  bodies,  will  be  speci- 
ally dealt  with  in  discussing  special  injuries. 

We  have  already  stated  that  fatal  hemor- 
rhage, from  the  large  vessels  of  the  extremities, 
rarely  occurs  on  the  battle  field,  and  that  when 
the  large  arteries  are  wounded,  the  hemorrhage 
is  either  so  immediately  fatal  that  no  assistance 
can  be  rendered,  or  it  ceases  spontaneously. 
The  nervous  depression  so  common  to  shot  wounds 
with  its  tendency  to  syncope,  and  its  control 
over  the  circulatory  organs,  checks  the  impulse 
and  supply  of  blood  through  the  injured  vessel, 
and  promotes  the  formation  of  clots.  Openings 
in  arteries  may  be  closed  by  foreign  bodies,  and 
in  such  cases  hemorrhage  would  recur  when 
these  are  extracted.  The  largest  arteries  may 
however,  be  wounded,  and  may  cease  bleeding 
spontaneously. 

The  only  means  of  detecting  this  injury  would 
be  in  examining  carefully  the  strength  of  pulsation 
in  the  vessel,  beyond  the  course  of  injury.  A 
diminution  of  its  force,  when  compared  to  that 
of  the  corresponding  vessel  in  the  opposite  limb, 
shows  conclusivelv  some  hindrance  to  the  circu- 


154  LIGATION    OF    ARTERIES. 

lation.  When  no  external  hemorrhage  exists,  an 
absence  of  pulsation  in  the  course  of  the  artery 
below  the  wound  is  the  only  means  of  detecting 
serious  injury  to  the  vessel,  and  it  often  decides 
whether  the  limb  should  be  at  once  amputated. 
The  presence  of  the  pulse  is,  of  course,  no  indica- 
tion that  no  injury  has  been  received.  Although, 
from  the  course  of  the  ball  and  the  flow  of  blood, 
we  know  that  the  main  vessel  of  the  limb  has 
been  injured,  if  the  bleeding  has  ceased  sponta- 
neously, or  by  the  pressure  of  the  sponge,  or 
compress,  which  was  tied  over  the  wound,  the 
artery  should  not  be  interfered  with.  In  by  far 
the  majority  of  cases,  if  proper  precautions  be 
taken,  there  will  be  no  recurrence  of  the  hemor- 
rhage. The  patient  should  be  kept  perfectly 
quiet,  free  from  all  causes  of  excitement,  at  per- 
fect rest;  and  to  ensure  that  the  limb  shall  not 
be  moved,  a  bandage  should  be  carefully  applied 
from  the  extremity  of  the  limb  upward,  and  a 
long  splint  secured.  The  flannel  bandage  being 
the  most  elastic,  is  the  best  material  for  such 
methodical  pressure  and  support.  Elevation  of 
the.  limb  will  add  much  to  the  efficacy  of  the 
preventive    treatment. 

The    ligation    of  an   avtery,    which    is    the    only 
sure  precaution  against  the  return  of  hemorrhage, 


LIGATION    OF    ARTERIES.  155 

is  not  only  a  difficult  operation,  requiring  much 

skill  for  its  successful  performance,  but  when 
necessary  to  control  the  bleeding  from  a  recent 
wound,  becomes  a  very  dangerous  one  to  the 
safety  of  the  limb  or  life  of  the  individual.  In 
cases  of  disease,  nature,  always  on  the  alert,  has 
enlarged  contiguous  blood-vessels,  which  are  ready 
to  assume  all  the  functions  of  the  one  requir- 
ing obliteration.  In  a  wound  in  a  healthy  person 
no  such  preparation  has  been  made ;  and  in  cut- 
ting off  the  main  supply  of  blood  through  a  limb 
it  becomes  a  very  serious  question,  often  answered 
by  the  loss  of  the  limb  and  even  life,  whether  the 
circulation  will  be  re-established  in  time  to  save 
the  member  from  mortifying.  When  a  ligature 
is  placed  upon  the  main  artery  of  a  limb  for 
disease,  previous  developments  in  the  collateral 
circulation  have  been  made  to  such  an  extent,  that 
the  extremity  may  not  even  lose  temperature 
after  the  ligation,  and  as  there  is  no  diminution 
of  the  nutrient  supply  there  is  no  fear  of  mortifi- 
cation. If  placed  on  a  healthy  vessel  for  an  in- 
jury, the  limb  at  once  becomes  pale  and  cold, 
requiring  the  application  of  artificial  warmth  and 
enveloping  in  flannels  to  support  life  in  it  until 
the  circulation  be  re-established,  when  the  limb 
becomes  actually  warmer  than  its  colleague.     The 


156  LIGATION    OF    ARTERIES. 

arterial  supply  is  now  disseminated  in  vessels 
much  nearer  to  the  surface  than,  before,  where  its 
chief  channel  was  deeply  embedded  in  the  tissues. 
The  rapidity  of  this  collateral  development  in  the 
limb  is  well  exhibited  in  primary  and  secondary 
amputations.  When  a  thigh  is  amputated  in  a 
healthy  portion,  very  seldom  are  there  more  than 
three  or  four  ligatures  required  to  stop  all  oozing 
and  render  the  stump  quite  dry.  If  the  amputa- 
tion be  necessary  at  the  same  point  three  or  four 
days  after  an  injury  to  the  main  vessel  has  been 
received,  the  number  is  greatly  increased  :  as 
many  as  twenty-eight  arteries  have  been  ligated 
by  Langenbeck  after  amputating  a  thigh  under 
similar  circumstances. 

Should  active  hemorrhage  continue  and  show 
no  disposition  to  cease,  the  wound  should  be 
dilated,  the  bleeding  mouths  of  the  artery  found, 
and  a  ligature  applied  both  <ihi>rt  ami  heloir  the  injur;/. 
This  has  become  the  fixed  practice  and  the  only 
safe  one,  taking  its  place  among  the  aphorisms  of 
surgery.  The  universal  adoption  of  this  practice 
is  not  only  based  upon  experience  and  observa- 
tion, but  could  be  determined  a  priori  from  the 
physiology  and  anatomical  distribution  of  arteries. 

All  surgeons  are  familiar  with  the  anastomosis 
or  collateral  circulation   in  blood-vessels.      A\  nen 


LIGATION    OF    ARTERIES.  157 

the  current  of  blood,  is  stopped  at  any  one  point, 
it  will  soon  find  its  way  through  many  circuitous 
routes  round  to  the  very  point  through  which  its 
straight  course  had  been  checked.  When  an  arte- 
ry is  divided,  it  is  well  known  that,  owing  to  its 
muscular  and  elastic  structure,  that  portion  above 
the  wound  at  once  contracts  and  retracts,  so  that 
the  tube  which  was  before  cylindrical,  now  resem- 
bles a  claret  bottle  with  a  much  constricted  neck. 
A  clot  of  blood  soon  forms  in  this  mouth  and 
neck,  and  the  passage  of  the  blood  is  intercepted. 
In  the  lower  portion  of  the  divided  vessel  similar 
changes  are, going  on,  but  not  to  so  great  an  extent. 
The  contraction  (owing  to  the  severing  of  the 
nerves  which  give  tone  to  the  arterial  walls)  is 
only  partial,  the  walls  being  to  a  certain  extent 
paralyzed,  and  so  little  blood  remains  in  the  tube 
that  a  very  small  and  indifferent  clot  is  formed. 
"When  the  upper  portion  of  the  artery  is  firmly 
closed,  preventing  all  egress  to  blood,  the  lower 
portion  remains  patulous,  inviting  discharge.  As 
soon  as  the  blood-currents  find  their  way  by  cir- 
cuitous channels,  it  wells  up  from  the  wound  in  a 
continuous  purplish  stream,  all  impulse  having 
been  lost,  and  also  most  of  the  oxygen  by  the 
long  roundabout  way  which  the  blood  now  takes. 
The  darkness  of  the  blood  will  depend  upon  the 


158  LIGATION    OF    ARTERIES. 

difficulties  of  the  circuitous  passage;  the  rule, 
however,  is  scarlet  or  arterial  blood  from  the 
upper  end  of  the  vessel,  dark  or  veinous  colored 
blood  for  its  lower  end. 

Guthrie  lavs  down  the  two  following  rules  as 
the  great  principles  of  surgery,  to  be  observed  in 
the  cases  of  wounded  arteries,  and  which  ought 
never  to  be  absent  from  the  mind  of  the  surgeon  : 

1.  That  no  operation  ought  to  be  performed  upon 
a  wounded  artery  unless  it  bleeds. 

2.  That  no  operation  is  to  be  done  for  a  wounded, 
artery  in  the  first  instance,  but  at  the  sp>ot  injured, 
unless  sack  operation  not  only  appears  to  be  hit  is 
impracticable. 

When  it  is  necessary  to  ligate  an  artery,  the 
surgeon  must  be  guided  by  his  anatomical  knowl- 
edge, and  by  the  pulsation  in  rinding  it.  In  di- 
lating the  wound  so  as  to  expose  the  bleeding 
mouths,  the  incisions  should  be  made  parallel  to 
the  course  of  the  vessel,  and  sufficiently  free  to 
facilitate  the  search.  The  dissection  is  carefully 
conducted,  dividing  layer  by  layer,  and  avoiding 
the  nerves  and  veins  which  always  accompany 
the  large  arteries.  When  the  bleeding  mouth 
is  so  exposed  that  the  origin  of  the  jet  of  blood 
is  seen,  the  vessel  is  transfixed  by  a  tenaculum 
drawn  out  and  secured  as  it  would  be  in  a  stump 
after  amputation. 


LIGATION    OF    ARTERIES.  159 

Where  it  is  impossible  to  ligate  the  bleeding- 
vessel  at  the  point  wounded,  a  point  should  be 
selected,  at  which  the  vessel  is  comparatively 
isolated,  easily  discovered,  and  free  from  large 
collateral  branches.  In  exposing  it  make  a  free 
incision.  The  common  mistake  that  most  sur- 
geons make  is  a  small  incision,  which  hampers 
the  search.  When  we  approach  the  artery,  use 
the  grooved  director  to  isolate  those  cellular 
layers  in  which  the  vessel  is  always  found.  The 
point  of  the  knife  should  never  be  used  for  this 
purpose.  The  lips  of  the  wound  should  be  drawn 
asunder  by  an  assistant,  so  as  to  give  to  the 
operator  the  light  necessary  for  accomplishing 
speedily  and  successfully  the  ligation.  In  all 
cases  requiring  such  an  operation,  it  is  desirable 
to  have  the  patient  completely  under  control, 
and,  therefore,  chloroform  should  be  adminis- 
tered. 

When  the  artery  is  found,  and  the  ligature 
passed  under  it,  before  tying  it  be  quite  sure 
that  it  is  the  vessel,  and  it  alone,  and  not  the 
nerve  that  has  been  seized.  To  be  satisfied  on 
this  point,  it  is  only  necessary  to  draw  slightly 
upon  the  thread,  and  examine  above  and  below 
to  see  whether  the  pulsation  has  altogether 
ceased  below   the    ligature.     Having   determined 


160  LIGATION    OF    ARTERIES. 

that  the  thread  is  properly  placed,  it  is  then  firm- 
ly tied,  the  ends  are  brought  out  of  the  wound 
and  secured  under  a  strip  of  adhesive  plaster, 
attached  to  the  immediate  neighborhood  of  the 
wouud.  This  mode  of  disposing  of  it  will  pro- 
tect it  from  becoming  entangled  in  the  ordinary 
dressing,  and  be  drawn  upon  when  these  are 
daily  removed.  Water  dressings  would  he  the 
proper  after-treatment.  The  thread  will  have 
come  away  spontaneously,  by  the  eighth,  twelfth 
or  sixteenth  day,  according  to  the  size  of  the 
vessel  ligated. 

When  it  is  necessary  to  ligate  the  artery  in 
its  eourse  above  the  seat  of  hemorrhage,  I 
would  prefer  using  a  fine  silver  wire  ligature. 
This  is  well  twisted  upon  the  artery,  and  then 
cut  oft',  leaving  only  the  loop  with  one  or  two 
twists  in  the  wound.  The  advantage  is,  that 
the  foreign  body  being  very  small,  not  weighing 
more  than  one-third  or  one-half  of  a  grain, 
creates  but  little  irritation,  and  the  wound  can  be 
healed  in  a  few  days  by  quick  union.  This 
will  protect  the  patient  from  the  dangers  of  sup- 
puration, pyaemia,  or  secondary  hemorrhage  from 
the   ligated  point. 

In  the  treatment  of  reducible  inguinal  hernia, 
where  I  have  obtained  permanent  cures  by  sewing 


TREATMENT    OF    WOUNDS. 


161 


the  columns  of  the  ring  together  by  silver  wire 
sutures  passed  subcutaneously,  the  small  loop  of 
wire  remains  permanently  in  the  inguinal  region 
under  the  skin,  and  gives  no  trouble.  From  ex- 
perience, in  limited  periods,  I  have  reason  to 
believe  that  it  will  remain  innocuous  for  a  life- 
time. 

The  silver  wire  should  not  be  applied  to 
arteries  in  a  suppurating  wound,  or  where  sup- 
puration and  sloughing  must  ensue,  as  in  cleans- 
ing the  wound  it  would  be  liable  to  be  dis- 
turbed, and  may  be  the  cause  of  bleeding. 
Should  the  ligation  of  the  large  arteries  at 
the  root  of  the  neck  ever  prove  successful,  it 
must  be  by  the  adoption  of  the  silver  wire 
ligature,  which  can  be  twisted  sufficiently  to 
cause  a  certain  degree  of  irritation  in  the  outer 
coats  of  the  artery,  and  induce  a  copious  deposit 
of  lymph  for  incarcerating  the  wire  and  thicken 
these  coats,  without  causing  sloughing  of  the 
inner   coats  or  opening  the  vessel. 

Local  treatment  of  wounds. — Having  removed 
all  foreign  bodies,  and  hemorrhage  having  ceas- 
ed, the  dressing  now  required  should  be  of 
the  simplest  description.  It  is  known  that  gun- 
shot wounds,  favoring  the  contused  variety. 
14 


162  TREATMENT    OF    WOUNDS. 

show  a  constant  disposition  to  suppurate  and 
often    to    slough.      This  process  of  suppuration  is 

not  necessary  to  the  healing  of  the  wound,  and  should 
be  kept  in  subjection  as  much  as  possible.  This  is 
effected  by  the  continued  application  of  cold, 
which,  by  keeping  down  excessive  reaction,  and 
keeping  out  an  excess  of  blood,  diminishes  the 
source  of  the  pus  supply,  and  thus  hastens  the 
cure.  In  former  times,  suppuration  was  consi- 
dered essential  in  the  healing  of  all  wounds, 
by  permitting  the  escape  of  so  much  poisonous 
matter,  which  had  accumulated  in  the  system, 
and  Avhich  must  either  now  find  a  vent,  or,  if 
retained,  would  be  considered  the  satisfactory 
cause  of  any  sickness  which  the  wounded  man 
may  ever  suffer  from  hereafter.  The  wound  was 
therefore  plugged  with  a  lint  tent,  piles  of  greasy 
lint  in  cushions  were  applied,  and  after  covering 
with  a  sufficient  number  of  compresses  and  band- 
ages, a  forcing  bed  was  formed,  which  supplied 
pus  to  the  satisfaction  of  all  interested  ;  and  it 
was  common  enough  to  see  life  drain  away  from. 
this  opening. 

This  smothering  of  wounds  and  smearing -on 
of  greasy  ointments,  which  the  wounded  formerly 
encountered,  was  a  second  enemy,  far  more  fatal 
than    the    enemy  on    the   battle    field  :    as    in    its 


TREATMENT    OF    WOUNDS.  163 

ranks  ranged  exhausting"  suppuration,  with  its 
hectic ;  pyaemia,  with  its  rapid  poisoning ;  hos- 
pital gangrene,  with  its  sudden  collapse,  and 
erysipelas,  with  its  thousands  of  victims,  broken- 
down  constitutions,  tedious  convalesence,  very 
protracted  cures,  and  endless  pain  and  annoy- 
ance. 

How  much  more  rational  is  the  present  prac- 
tice. Keep  away  all  hot  dressings,  which  invite 
blood  to  the  part.  Vote  poultices  a  curse,  and 
eject  the  dirty,  troublesome  application.  Guthrie 
says  poultices  should  not  be  permitted  in  a  mili- 
tary hospital ;  they  are  generally  cloaks  for  negli- 
gence, and  sure  precursors  of  amputation  in  all 
serious  injuries.  With  more  recent  writers  they 
even  meet  with  less  favor. 

The  only  dressing  required  for  wounds,  of  whatever 
character,  is  the  irate)'  dressing,  and  it  should  be  used 
as  follows  :  apply  a  single  thickness  of  wet  linen 
or  cotton  cloth  over  the  wound,  allowing  it  to  ex- 
tend over  a  considerable  surface.  If  possible, 
cover  this  with  a  layer  of  oiled  silk,  waxed  cloth, 
or  india-rubber  tissue.  A  second  layer  of  cloth  or 
a  band  secures  the  two  former  layers  in  position, 
so  that  they  will  not  be  displaced  by  the  motions 
of  the  patient  in  sleeping.  Then,  either  squeeze 
cold  water  frequently  upon  this  outer  cloth,  which 


164  TREATMENT    OF    WOUNDS. 

will  keep  up  the  low  temperature ;  or  what  is  a 
much  more  convenient  and  less  laborious  plan, 
suspend  a  bucket  or  some  vessel  containing 
water  in  the  neighborhood  of  the  wound,  having 
a  narrow  slip  of  cloth,  or,  what  is  better,  a  lamp 
wick  from  the  suspended  vessel  to  the  bandage 
upon  the  wounded  limb.  By  capillary  attrac- 
tion, a  constant  stream  of  water  is  carried  from 
the  vessel  to  the  dressing,  and  by  its  evaporation, 
robbing  the  skin  of  its  animal  temperature 
to  .get  a  sufficient  quantity  of  heat  to  convert 
the  water  into  aqueous  vapor,  it  refrigerates  the 
limb.  The  advantage  of  using  the  oiled  silk, 
waxed  cloth,  or  india-rubber  tissue  is,  that 
should  the  water  supply  accidentally  give  out 
in  the  suspended  vessel,  the  piece  of  cloth  be- 
neath it  remains  moist  upon  the  wound.  The  wet 
cloth  absorbs  the  discharges,  and  should  be 
changed  two  or  three  times  a  day,  it  being  well 
understood  that  they  be  disturbed  as  "seldom  as 
possible,  compatible    with    cleanliness. 

The  surgeon  should  never  be  in  haste  to  change 
the  cold  for  warm  applications.  Should  the  vir- 
tues of  a  poultice  be  called  into  requisition,  a  soft 
wet  compress  covered  with  oiled  silk  and  secured 
by  a  flannel  roller  or  outer  compress,  is  always  at 
hand,  and  will  be  found  to  combine,  in  a  simple 


TREATMENT    OF    WOUNDS.  105 

form,  all  the  properties  of  a  poultice.  It  is  light, 
moist,  soft,  and  is  kept  warm  by  absorbing  animal 
heat,  which  the  oiled  silk  and  outer  compress 
retains.  If  we  add  to  these,  cleanliness,  facility 
of  medication,  and  the  readiness  with  which  an 
impromptu  dressing  can  be  made,  we  find  an 
array  of  advantages  which  excludes  all  substi- 
tutes. 

A  more  effectual  mode  of  keeping  down  reac- 
tion is,  by  using  ice  bladders,  which  are  placed 
upon  the  india-rubber,  waxed  or  oiled  silk  cover- 
ing. These  are  of  very  general  application,  and 
make  the  least  call  upon  the  personal  attention  of 
nurses.  Whenever  ice  is  used,  never  apply  it  directly 
to  the  skin,  but  always  through  the  intervention  of  com- 
presses, which  may  be  made  sufficiently  thick  to 
accommodate  the  application  to  the  sensitiveness 
of  the  patient.  AYhen  possible,  these  bladders 
should  be  of  india-rubber  or  gutta-percha.  A 
large  supply  of  these  should  always  be  on  hand. 
The  animal  bladder  is  a  miserable  substitute,  as 
it  is  not  only  a  very  dirty  application,  allowing 
the  water  to  ooze  out  and  keep  the  patient  con- 
stantly wet,  but  the  bladders  become  very  offen- 
sive, and  are  soon  destroyed. 

Cold  water  is  the  only  proper  and  universal  antiphlo- 
gistic that  can  be  applied  to  wounds.     It  has  the  con- 


166  TREATMENT    OF    WOUNDS. 

venience  of  always  being  at  hand,  it  keeps  up  a 
uniform  action,  is  clean,  simple,  cheap,  agreeable 
to  the  feelings  of  the  patient,  easily  obtained, 
easily  applied,  demands  least  care  from  the  nurses, 
who  have  their  hands  usually  full,  and  is  withal 
effectual.  With  the  judicious  application  of  cold 
the  surgeon  can  defy  inflammation.  Cold  acts  by 
keeping  down  temperature,  con  stringing  vessels, 
and  keeping  blood  from  the  part  injured;  so  that 
inflammation,  which  consists  in  the  engorgement 
of  blood-vessels  and  an  excessive  supply  of  blood, 
cannot  get  a  foothold.  Heat,  redness,  pain  and 
swelling,  all  depend  upon  congestion ;  control 
the  supply  of  blood  to  a  part,  and  inflammation  is 
kept   in  abeyance. 

As  the  advantages  of  cold  water  dressings  are 
obtained  through  the  evaporating  properties  of 
water,  this  action  may  be  increased  by  medi- 
cating it  with  saline  substances  or  alcoholic 
tinctures.  Sugar  of  lead,  sulphate  of  zinc,  tan- 
nin, muriate  of  ammonia  or  laudanum,  spirits  of 
camphor,  and,  especially,  tincture  of  arnica  would 
be  useful  adjuvants.  Whilst  the  irrigation  is  going 
on,  the  compresses  next  the  skin  may  be  mois- 
tened every  three  or  four  hours  with  any  of  the 
above  preparations.  Should  the  wounded  patient 
feel   chilly,  the   cold  dressings    will   not  be   used 


TREATMENT    OF    WOUNDS.  167 

until  reaction  has  taken  place.  There  are  a  few- 
persons  with  whom  cold  water  is  not  admissible. 
In  all  cases  the  feelings  of  the  patient  will  he  our 
guide  as  to  the  applicability  of  the  remedy. 
When  not  grateful  and  refreshing  to  the  patient, 
but,  on  the  contrary,  the  cause  of  complaints,  the 
irrigation  must  be  superseded  by  a  wet  compress, 
covered  with  oiled  silk  or  a  waxed  cloth.  This 
will  soon  attain  the  temperature  of  the  body,  and 
will  keep  the  parts  moist  and  soft.  The  dress- 
ing requires  to  be  changed  twice  in  twenty-four 
hours;  not  that  the  compress  w7ould  get  dry,  for 
the  perspiration  from  the  part  which  is  kept  in 
by  the  oiled  silk  w/ould  bathe  it  in  a  continual 
and  permanent  moisture.  The  object  in  changing 
is  to  get  rid  of  this  secretion,  which,  by  decom- 
posing, would  irritate  the  wound. 

A  question  of  great  moment  is,  when  should  we 
desist  from  water  apjrtieations  and  change  for  some 
more  useful  or  appropriate  dressing?  According  to 
the  present  rational  views  of  surgeons,  no  other 
dressing  is  ever  required,  however  serious  a 
wound  may  be.  As  long  as  inflammation  threat- 
ens, so  long  is  it  necessary  to  prevent  engorge- 
ments. As  long  as  suppuration  is  kept  up,  so 
long  will  the  efficacy  of  cold  be  required  to  con- 
stringe  the  blood-vessels  and  control  the  source  of 
the  purulent  supply. 


168  TREATMENT    OF    WOUNDS. 

Pus,  which  we  call  a  healthy  fluid,  is  a 
heavy  drain  upon  the  system.  It  is  made  from 
the  richest  ingredients  of  the  blood,  which  were 
intended  for  the  repair  of  tissues.  Once  converted 
into  pus,  it  is  unfit  for  any  further  useful  purpose, 
and  is  therefore  a  wTaste  of  precious  material. 
This  discharge  is  not  more  necessary  to  the  heal- 
ing of  wounds  than  to  the  nutrition  of  the  body. 
Extensive  wounds,  healing  by  the  first  intention, 
do  very  well  without  its  intervention.  Large  sub- 
cutaneous wounds,  when  even  their  sides  are  not 
kept  in  apposition,  heal  wTith  rapidity  without  the 
formation  of  pus.  Under  a  scab  we  find  tissues 
form,  by  what  has  been  called  the  remodeling 
process,  without  it;  and  it  should  be  our  constant 
effort  to  heal  all  wounds,  and  I  would  say  espe- 
cially gunshot  wounds,  with  the  least  possible 
discharge.  Hence  the  water  dressing  can  be  con- 
tinued beneficially  for  weeks,  or  as  long  as  the 
wound  remains  unhealed.  The  most  recent 
writers  on  gunshot  wounds  state  that  the  wet  cloth 
should  be  kept  on  until  cicatrization  is  completed; 
and  that  no  other  application  so  protects  and  pro- 
motes the  formation  of  new  skin.  There  are  a 
long  list  of  ointments  which  have  heretofore  held 
universal  sway  in  the  treatment  of  wounds.  All  of 
these  can  be  dispensed  with  for  the  more  simple 


SECONDARY    HEMORRHAGE.  169 

dressing.  Should  the  wound  require  stimulation, 
the  nitrate  of  silver  wash,  grs.  xx  to  the  ounce, 
when  brushed  over  the  part,  will  suffice ;  or  tinc- 
ture of  iodine,  or  iron,  or  some  stimulating 
astringent  might  be  equally  applied  in  addition 
to  the  water  dressing,  so  that  any  imaginary  con- 
dition of  the  wound  might  be  successfully  met 
by  the  medicated   wet  cloth. 

The  disturbing  influences  in  the  healing  pro- 
cess of  wounds  are  numerous,  and  most  of  them 
are  capable  of  correction  without  much  trouble. 
Among  these  are  found  imperfect  transportation 
over  rough  roads  ya  improper  vehicles;  bad  at- 
tendance, such  as  rough  or  too  frequent  examina- 
tions ;  useless  bandaging,  which  promotes  infil- 
tration ;  too  frequent  dressing ;  improper  food  ; 
scorbutic,  syphilitic,  and  other  diseases;  the  mor- 
al depression  of  defeat,  and  above  all,  the  imper- 
fect ventilation  and  undue  regard  to  cleanliness 
in  the  wards  of  military  hospitals. 

We  have  already  said  that  a  surgeon  is  never 
warranted  in  cutting  down  upon  an  artery  and 
tying  it  upon  suspicion — he  must  be  an  eye-wit- 
ness of  the  hemorrhage,  and  see  that  it  cannot  be 
controlled  by  other  means.  The  ligation  of  an 
artery  is  always  a  troublesome  operation,  and 
from  the  fear  of  subsequent  mortification,  always 
15 


170  SECONDARY    HEMORRHAGE. 

jeopards  the  limb,  and  necessarily  with  it  the 
life  of  the  patient.  This  is  specially  the  case  in 
recent  wounds,  before  nature  has  prepared  a 
collateral  circulation,  so  that  the  rule  which  we 
have  laid  down  is  imperative,  never  ligate  an  artery, 
however  large,  in  which  hemorrhage  has  spontaneously 
ceased;  and,  moreover,  that  a  good  compress  is 
usually  sufficient,  when  applied  immediately  after 
the  receipt  of  injury  on  the  battle  field,  to  stop 
the  bleeding  even  from  the  largest  vessels,  when 
position,  quiet,  rest,  and  other  prophylactics  will 
prevent  its  return. 

In  the  ordinary  course  o£  gunshot  wounds, 
suppuration  is  established  about  the  fifth  or  sixth 
day,  when  the  track  of  the  wound  commences 
to  be  organically  cleansed  of  all  those  tissues 
which  have  been  crushed  and  so  much  injured  as 
to  be  no  longer  preserved  among  the  living  tissues. 
During  the  elimination  of  these  destroyed  parts, 
where  the  precaution  of  rest  and  absolute  quiet 
has  not  been  enforced,  hemorrhage,  called  se- 
condary, appears.  All  injuries  to  large  arteries 
threaten,  sooner  or  later,  to  produce  secondary 
hemorrhage.  However  large  the  artery  reopened 
by  this  process,  the  escape  of  blood  seldom 
occurs  with  an  impulse,  but  flows  away  in  a 
continuous  stream,  which  marks  its  escape  from 
the  lower  end  of  the  vessel. 


SECONDARY    HEMORRHAGE.  171 

When  hemorrhage,  even  from  the  femoral 
artery,  has  been  arrested  for  twelve  hours,  the 
efforts  of  nature  are  usually  sufficient  to  prevent 
its  return  from  the  upper  portion  of  the  artery, 
although  not  from  the  lower  end  of  the  vessel ;  so 
that  when  the  main  vessel  of  a  limb  is  divided  by 
a  ball,  once  primary  hemorrhage  is  controlled, 
the  great  fear  is  then  from  bleeding  through  the 
lower  end  of  the  artery,  and  from  mortification  of 
the  extremity.  Any  hemorrhage,  after  twenty- 
four  hours,  would  be  considered  secondary,  and 
would  require  special  treatment.  As  long  as  the 
wound  remains  open  hemorrhage  may  make  its 
appearance,  and  it  is  not  until  a  cure  is  effected 
and  the  parts  are  cicatrized,  that  the  patient  is 
positively  safe  from  this  dangerous  complication. 
Cases  are  recorded  where  it  has  occurred  ninety 
days  after  the  vessel  had  received  injury.  Unless 
the  causes  of  this  hemorrhage  be  perfectly  under- 
stood, the  rules  laid  down  for  treatment  will  not 
be  duly  appreciated. 

In  speaking  of  the  behavior  of  the  two  ends 
of  a  divided  artery,  we  have  already  stated  that 
the  upper  end  contracts  vigorously,  diminishes 
its  calibre  at  the  mouth,  and  for  some  distance 
up  the  tube,  until  it  simulates  in  its  proportions 
the  neck  and  body  of  a  claret  bottle.     The  blood, 


172  SECONDARY    HEMORRHAGE. 

impeded  in  its  outward  course,  allows  a  clot  to 
form,  which,  acting  as  a  stopper,  shuts  up  the 
open  mouth.  The  plug  is  continued  in  the 
contracted  artery  to  the  first  collateral  branch  as 
a  clot  of  blood,  which  nearly  fills  its  cylinder. 
The  lower  portion  of  the  vessel,  having  been  in 
a  measure  paralyzed  by  the  division  of  its  coats, 
which  had  cut  off  its  supply  of  nerves,  acts  with 
much  less  energy.  The  diminution  of  its  calibre 
depends  more  upon  the  removal  of  distension  from 
its  elastic  walls  than  from  the  contraction  of  its 
muscular  fibres.  The  result  is,  that  it  remains 
more  or  less  patulous;  and  as  the  supply  of 
blood  from  above  is  cut  off,  there  is  but  little 
arterial  blood  in  it  to  clot  and  plug  it  up.  As 
soon  as  this  barrier  or  clot  is  placed  upon  the 
main  thoroughfare,  at  the  upper  wound,  prevent- 
ing; the  blood  from  following;  its  accustomed  chan- 
nel,  nature  is  at  once  busy,  opening  and  enlarging 
the  circuitous  by-ways  and  alleys  of  the  circulation, 
so  as  to  restore  the  supply  to  the  extremity  threat- 
ened with  starvation,  or,  in  surgical  parlance, 
mortification.  As  when  upon  a  high  road  a  bridge 
spanning  a  stream  is  destroyed,  travellers  seek  a 
ford  higher  up  by  which  they  may  return  to  the 
thoroughfare  beyond  the  impediment,  so  the 
blood   taking   the    nearest    bv-roads    above,    soon 


TREATMENT    OF    SECONDARY    HEMORRHAGE.  173 

gets  around  the  obstacle,  and  empties  itself  into  the 
main  channel  below  it.  The  blood  here  changed 
in  its  direction,  and  not  opposed  by  valves,  passes 
up  as  well  as  down  the  limb,  and  finding  an 
open  gate  at  the  lower  torn  mouth  of  the  ves- 
sel, escapes.  This  fluid,  moreover,  in  its  round- 
about course,  has  lost  much  of  its  vivifying  prop- 
erties ;  much  of  its  oxygen  is  gone,  and  carbonic 
acid,  ammoniacal  gases  and  the  like,  have  taken 
its  place,  marred  its  brilliant  color,  and  dimin- 
ished its  clotting  properties.  No  material  then 
exists  for  stopping  up  the  vessel,  as  in  the  upper 
end  of  the  divided  artery,  and  the  result  is,  that 
secondary  hemorrhage  nearly  always  occurs  from 
the    lower   ends. 

This  being  well  understood,  we  can  now  ex- 
plain wlvy  a  ligature  placed  on  the  upper  orifice 
alone,  or  on  the  course  of  the  artery  above  the 
Injury,  should  not  stop  but  only  temporarily  con- 
trol the  hemorrhage.  As  soon  as  the  collateral 
circulation  above  the  ligated  point  is  re-establish- 
ed, the  lower  opening  in  the  vessel  remaining  as 
before,  hemorrhage  must  recur,  or,  if  this  circu- 
lation is  not  re-established  mortification  must 
follow.  The  rule  then  is  imperative,  ligate  both  ends 
of  the  vessel  at  the  point  wounded;  this  is  the  only  safe 
course   to  pursue.     Another  strong  reason  why  the 


174  TREATMENT    OF    SECONDARY    HEMORRHAGE. 

ligature  should  be  applied  to  the  wounded  ends 
of  the  artery  is,  that  there  is  always  some  un- 
certainty as  to  the  vessel  injured.  The  very 
serious  and  often  fatal  operation  of  ligating  the 
femoral  artery  has  been  performed  for  injury  to 
one  of  its  branches,  which  had  not  been  suspected 
until  a  post-mortem  examination  revealed  the 
source  of  bleeding.  When  the  ligature  is  ap- 
plied to  the  bleeding  mouths,  this  accident  can- 
not happen. 

The  course  ivhich  should  be  adopted  in  the  case 
of  an  injured  artery  bleeding,  is  as  follows:  After 
the  hemorrhage  has  once  been  controlled,  through 
either  some  carelessness  on  the  part  of  the  sur- 
geon or  restlessness  on  the  part  of  the  patient, 
getting  up  to  help  himself  when  he  had  strict 
orders  to  the  contrary,  etc.,  or  perhaps  from  rough 
transportation  over  bad  roads,  or  the  sloughing  of 
the  wound,  hemorrhage  reappears,  the  limb  should 
be  at  once  bandaged  from  the  extremity  up- 
ward, making  careful,  regular  pressure,  so  as  to 
diminish  the  quantity  of  circulating  fluid.  Over 
the  course  of  the  main  artery,  and  for  some  little 
distance  below  the  wound,  a  compress  saturated 
or  not  with  some  of  the  styptic  preparations  of 
iron  should  be  firmly  secured,  the  bandaging  of 
the   limb    extending  to  one  or  two  inches  above 


TREATMENT    OF    SECONDARY    HEMORRHAGE.  175 

the  injury.  The  patient  is  then  to  be  placed 
upon  his  back,  the  limb  elevated  and  an  ice 
bladder  applied  over  the  wound.  Absolute  quiet 
should  be  enjoined,  and  secured  by  a  large  dose 
of  opium. 

In  many  cases,  this  dressing  will  bring  about  the 
desired  object,  when  assisted  by  those  internal  re- 
medies which  control  the  force  of  the  circulation, 
as  veratrum  viride,  digitalis,  etc.  B3'  the  use  of 
the  compress  saturated  with  per  chloride  of  iron, 
in  connection  with  absolute  rest,  I  have  succeeded 
in  checking  secondary  hemorrhage  from  the  caro- 
tid artery  after  the  escape  of  the  ligature.  But 
should  the  parts  be  so  situated  that  this  pres- 
sure cannot  be  applied  for  a  sufficient!}"  long 
time,  or  should  it  not  control  the  bleeding,  then 
the  proper  course  is  to  ligate  the  mouths  of  the 
artery  in  the  wound  without  further  delay.  ISTo 
case  of  secondary  hemorrhage  should  destroy  life 
by  repeated  recurrence ;  a  surgeon  is  very  culpable 
who  permits  life  to  ebb  away  from  his  grasp.  Phy- 
sicians caunot  be  too  guarded  against  the  delusive 
attempts  at  stopping  the  bleeding  after  the  recur- 
rence of  secondary  hemorrhage,  it  is  certain  to 
return  and  certain  to  destroy  life,  as  experience 
repeatedly  proves.  Every  fresh  hemorrhage  in- 
creases the  dangers  and  doubles  the  risks,  there- 
fore, never  neglect  ligating  after  the  second  hemorrhage. 


176  TREATMENT    OF    SECONDARY    HEMORRHAGE. 

You  must  not  be  deterred  from  placing  a  liga- 
ture on  the  open  months  of  an  artery  in  a  suppur- 
ating wound,  on  the  deeply  grounded,  but  erro- 
neous idea,  that  the  artery  has  had  its  coats  soft- 
ened by  this  process.  Practical  surgery  shows  con- 
clusively, that  the  coats  are  tough  enough  to  sus- 
tain a  ligature  in  a  suppurating  wound,  and  there- 
fore the  rule  should  have  no  exception.  Li<i<i1c 
in  the  wound  under  (art/  circumstances,  when  it  is  jms- 
siblc.  The  swelling  and  infiltration  of  tissues,  ren- 
ders the  search  after  the  injured  artery  difficult, 
but  the  surgeon,  who,  looking  to  the  side  of  hu- 
manity, considers  it  a  sacred  duty  to  do  everything 
for  the  interest  of  the  wounded,  must  not  allow 
difficulties  to  interfere  with  his  proper  course. 
Safety  lies  alone  in  this  operation.  The  difficul- 
ties   must   be  met  and  overcome. 

The  following  appearances  will  be  observed 
in  the  wound,  and  will  assist  in  the  search  :  After 
dividing  the  infiltrated  tissues,  should  the  injury 
have  been  received  over  forty-eight  hours,  par- 
ticularly if  five  or  six  days  have  intervened,  the 
ends  of  the  vessel  will  be  found  incarcerated  in 
a  mass  of  greenish  yellow  fibrine  which  indicates 
in  a  remarkable  manner  their  situation.  That 
which  conceals  the  lower  mouth  of  the  vessel  is 
always  in  smaller  quantity.     Where  post-mortem 


TREATMENT    OF    SECONDARY    HEMORRHAGE.        177 

examinations  are  made,  a  probe  introduced  into 
the  artery  from  below  would  make  its  appearance 
at  a  point  under  the  yellow  patch,  raising  a 
thin  portion  as  it  protrudes;  and  should  the  pa- 
tient have  been  destroyed  by  secondary  hemor- 
rhage, an  opening  will  usually  be  found  in  this 
pellicle.  Through  the  upper  portion  of  the 
artery  the  probe  would  pass  down  with  much 
more  difficult}',  owing  to  a  contracted  tube 
plugged  with  coaguke — conditions  which  do  not 
exist  in  the  lower  portion.  These  lymphy,  yel- 
lowish green  spots  are,  then,  our  guides  after 
the  wound  has  been  freely  dilated. 

In  a  surgical  operation,  especially  in  ligating  ar- 
teries, never  cramp  oneself  from  the  fear  of  mak- 
ing too  large  an  opening;  the  error  is  always  on 
the  other  side.  Having  found  and  ligated  the 
orifices,  the  water  dressing  should  be  continued 
as  before,  care  being  taken  not  to  apply  it  should 
the  limb  become  cool  and  pale.  This  is  not  usu- 
ally the  case  after  secondary  hemorrhage,  for 
the  return  of  the  bleeding  indicates  a  re-estab- 
lished circulation,  which  the  ligature  at  the  bleed- 
ing mouths  cannot  now  influence  to  the  injury  of 
the  limb.  Should  it  be  impossible  to  find  the 
bleeding  mouths,  after  a  long  and  careful  search, 
then  we  will  be  reluctantly  compelled  to  adopt  the 


178         TREATMENT    OF    SFXONDARY    HEMORRHAGE. 

less  satisfactory  operation  of  ligating  the  artery 
above  the  wound  ;  hoping  that  it  may  obviate  fur- 
ther operation.  Often,  however,  when  this  last 
plan  has  been  adopted,  a  return  of  the  hemorrhage 
necessitates  a  second  ligature  upon  some  higher 
point;  and  should  this  fail,  as  is  not  frequently  the 
case,  amputation  of  the  limb  will  be  the  only  re- 
sort to  save  life.  Amputation  must  be  equally  re- 
sorted to  if,  after  the  application  of  a  ligature, 
the  circulation  not  being  re-established,  morti- 
fication of  the  limb  ensues.  In  either  case  am- 
putate above  the  seat  of  the  ligature,  so  as  to 
ensure  a  supply  of  blood  to  the  stump  for  its 
nutrition. 

These  are  some  of  the  dangers  incurred  when 
the  surgeon  does  not  adopt  the  only  proper  course 
to  stop  the  trouble  at  its  commencement.  Mili- 
tary hospital  statistics  show  heavy  mortuary  lists 
where  this  rule  is  not  recognized  and  followed. 
As  the  ligature  acts  as  a  foreign  body,  and  must 
come  away,  it  is  of  little  importance  what  is 
used  for  that  purpose,  a  strong  cotton,  flax  or 
silk  thread,  fulfils  all  the  indications  required. 
When  applied,  it  should  not  be  interfered  with 
until  it  has  either  come  away  of  its  own  accord, 
or  ten  to  fifteen  days  have  elapsed,  when  cau- 
tious tractions  might  be  attempted  to  hasten  its 
removal. 


PUNCTURED    WOUNDS.  170 

Silver  wire  lias  been  spoken  of  as  ligatures 
for  arteries.  However  well  it  ma}7  answer  in 
fresh  wounds  where  union  by  the  first  intention 
can  be  obtained,  it  is  quite  out  of  place  in  sup- 
purating- wounds,  as  when  ligatures  are  applied 
for   controlling-   secondary    hemorrhage. 

Punctured  wounds  made  by  the  bayonet  or  sabre, 
require  similar  treatment.  If  the  history  and 
appearances  clearly  indicate  the  character  of  the 
wound,  there  will  be  no  need  of  probing  for 
imaginary  foreign  bodies.  Such  wounds  usually 
bleed  more  freely  than  in  gunshot.  The  hem- 
orrhage is  susceptible  of  control  by  the  same 
means  ;  pressure  being  preferred  to  ligation  of 
arteries.  The  treatment  should  be  cold  water 
dressings,  —  irrigation  preferred.  Protect  the 
wound  from  air  if  possible,  by  covering  it  with 
adhesive  plaster,  or  collodion,  and  dress  it  as  sel- 
dom as  possible.  Once  probing  of  such  a  wound 
should  satisfy  the  curiosity  of  any  surgeon.  A 
frequent  repetition  of  this  meddlesome  surgery 
must  end  in  mischiet,  beside  the  needless  pain 
inflicted  upon  the  wounded   man. 

Should  a  bayonet  or  sabre  wound  transfix  one 
of  the  natural  cavities,  the  internal  injury  may 
be    rapidly  fatal  from  hemorrhage,  or  the  injury 


180  PUNCTURED    WOUNDS. 

inflicted  upon  the  contained  organs  may,  sooner 
or  later,  lead  to  the  destruction  of  the  wounded 
by  visceral  inflammation.  Under  ordinary  condi- 
tions, when  such  wounds  exist  in  the  extremi- 
ties, where  no  large  vessels  are  implicated,  they 
require  no  special  treatment.  It  is  a  class  of 
wounds  not  as  frequently  met  with  in  military 
surgery  as  one  would  suppose.  The  newly  intro- 
duced sabre  bayonet,  when  plunged  into  the 
body  leaves  but  little  work  for  the  surgeon. 
Such  cases  seldom  leave  the  battle  field  alive. 

When  the  ordinary  bayonet  has  buried  itself  . 
deeply  in  a  limb,  suppuration  may  appear  in  the 
march  of  the  wound.  Should  pus  be  suspected, 
and  fears  exist  that  it  may  be  pent  up  under  a 
fascia,  it  would  be  necessary  to  dilate  the  wound 
to  permit  of  its  free  escape.  Under  no  other  con- 
dition, except  for  serious  hemorrhage,  where  it  is 
necessary  to  ligate  the  open  mouths  of  the  bleed- 
ing vessel,  should  a  punctured  wound  made  by 
either  sword  or  bayonet  be  dilated. 

Simple  incised  wounds,  as  sabre  cuts,  will  be 
closed  by  adhesive  plaster  (or  sutures  which  are 
preferable,  should  there  be  any  tendency  to  gap- 
ing), to  be  followed  by  the  cold  water  dressing. 
Should  the  wound  be  not  of  a  serious  character, 
it  may  be  left  even   without   after-dressing — the 


HEALING    OF    GUNSHOT    WOUNDS.  181 

little  oozing  from  its  edges,  when  drawn  together 
by  straps  or  sutures,  dries  into  a  scab  along  the 
line  of  wound,  and  excludes  air  with  its  pernicious 
influences.  This  permits  of  the  remodelling  pro- 
cess, and  cicatrization  is  effected  without  suppu- 
ration. 

In  gunshot  wounds,  the  swelling  which  shows 
itself  a  fewT  hours  after  the  injury  has  been  re- 
ceived, continues  increasing  until  the  comple- 
tion of  the  third  day,  when  it  has  attained  its 
acme  with  commencing  suppuration.  Should 
sloughing  occur,  it  will  show  itself  by  the  sixth 
or  seventh.  On  the  eighth  or  ninth  day,  the 
slough  is  in  most  cases  separated  from  the  edges 
of  the  track  of  the  ball,  and  in  a  few  days  more 
will  have  disengaged  itself.  With  the  cleans- 
ing of  the  wound,  the  inflammation  gradually  sub- 
sides, the  swelling  diminishes,  purulent  discharge 
lessens  in  quantity,  and  the  wound  commences 
contracting.  The  middle  portion  of  the  track  first 
closes,  and  with  it,  the  opening  of  exit,  leaving 
a  funnel-shaped  canal,  which  diminishes  from  day 
to  day,  becoming  more  superficial,  until  no  depth 
is  left  to  the  orifice  of  entrance,  which  cicatrizes 
with  a  depression,  marking  distinctly  the  nature 
of  the  injury  which  has  been  received.  This  is 
the  ordinary  course  which  gunshot  wounds  take 
when  judiciously  treated  in  good  constitutions. 


182  GENERAL    TREATMENT. 

The  general  treatment  of  such  cases  consists  chief- 
ly in  interfering  with  the  general  health  as  little 
as  possible.  The  commonly  prescribed  antiphlo- 
gistic remedies  are,  with  but  few  exceptions,  not 
required.  The  endless  list  of  emetics,  purgatives, 
diuretics,  and  diaphoretics,  to  which  some  Euro- 
pean writers  still  cling  with  wonderful  tenacity, 
can  be  dispensed  with  with  benelit. 

Guthrie,  who  represents  this  class,  in  speaking 
of  the  inflamed  stage  of  gunshot  wounds,  says, 
that  the  treatment  for  subduing  this  should  be 
active:  "the  patient,  if  robust,  ought  to  be  bled 
(if  no  endemic  disease  prevails),  vomited,  purged, 
kept  in  the  recumbent  position,  and  cold  applied 
as  long  as  it  shall  be  found  agreeable  to  his  feel- 
ings; when  that  ceases  to  be  the  case,  warm 
fomentations  ought  to  be  resorted  to,  but  they 
are  to  be  abandoned  the  instant  the  inflammation 
is  subdued  and  suppuration  well    established." 

Active  purgation  and  vomiting  are  incompati- 
ble with  that  degree  of  quiet  which  is  laid  down 
as  a  fundamental  rule  in  the  treatment  of  gunshot 
wounds.  As  suppuration  is  usually  long  contin- 
ued, and  debility,  with  a  certain  degree  of  emacia- 
tion, usually  accompanies  the  march  of  gunshot 
wounds,  the  disposition  should  rather  be  to  harbor 
strength  to  support  this  drain  than  to  despoil  the 


INTERNAL    TREATMENT    OF    WOUNDS.  183 

system.  The  modern  practice  of  support  rather 
than  depletion  hastens  convalescence,  and  is  the 
only  rational  practice. 

General  and  local  blood  letting  are  only  re- 
quired in  a  few  special  injuries  of  particular 
organs,  which  will  be  hereafter  mentioned. 

Emetics,  as  such,  are  never  required  in  the  gene- 
ral treatment  of  wounds.  When  very  small  doses  of 
the  emetic  preparations  are  given,  to  induce  relax- 
ation and  for  o-eneralizino-  the  circulation,  in  this 
way  deriving  the  excess  of  blood  from  the  wound, 
they  may  be  useful.  Small  doses  of  tartar  emetic 
may,  with  other  remedies,  form  a  good  prescrip- 
tion in  cases  of  excessive  reaction.  Mild  purga- 
tives are  in  constant  requisition,  both  for  their 
detergent  as  well  as  derivatory  effects. 

The  granulations  of  a  wound  are  said  to  be  a 
better  index  of  the  condition  of  the  intestinal 
canal  than  the  tongue,  as  thejr  are  much  more 
impressible  by  any  cause  which  induces  an  irri- 
table condition  of  the  system.  Keeping  watch 
over  the  digestive  organs;  preventing,  by  prop- 
er diet,  any  indigestible  food  from  getting  into 
them,  whilst  the  excretions  which  empty  into  this 
great  sewer  are  not  allowed  to  remain  and  disturb 
the  system,  will  be  at  all  times  judicious  practice. 
Diaphoretics   and   diuretics   are  the   milder  anti- 


184  INTERNAL    TREATMENT    OF    WOUNDS. 

phlogistic  and  derivative  remedies,  which  may 
frequently  be  called  upon  to  quiet  the  pulse  and 
equalize  the  circulation. 

The  ordinary  febrile  reaction  which  so  fre- 
quently follows  the  receipt  of  severe  injury, 
should  give  the  surgeon  no  annoyance  per  se. 
It  is  only  a  symptom,  an  indication  of  the  extent 
of  sympathy  between  the  local  irritation  and  the 
system  at  large.  When,  by  judicious  local  treat- 
ment, the  nervous  excitement  near  the  wound 
subsides,  the  pulse  will,  pari  passu,  lose  its  fre- 
quency and  irritability.  It  is  not  a  disease  within 
itself,  requiring  to  be  especially  attacked.  In  the 
general  treatment  of  wounds,  diet  and  rest  are  the 
two  great  remedies,  which  in  by  far  the  majority 
of  wounds,  even  the  most  serious,  are  all  that  is 
required  for  successful  treatment.  Should  there 
be  an  excess  of  general  excitement,  which  a 
purge  with  a  diaphoretic  or  diuretic  is  not  able  to 
quiet,  we  would  administer  to  such,  some  one  of 
that  class  of  medicines  wdiich  are  known  to  con- 
trol the  excitement  of  the  circulation,  quiet  the 
brain,  and  act  as  sedatives  upon  the  nervous  sys- 
tem generally,  as  opium,  hyoscyamus,  conium, 
belladonna,  digitalis,  veratrum  viride,  etc. 

When  local  reaction  is  excessive,  with  great 
swelling  and  heat,  there  is  a  class  of  medicines 


INTERNAL    TREATMENT    OF    WOUNDS.  185 

which  might  be  given  with  advantage.  They 
act  by  increasing  the  tone  of  blood-vessels,  and 
thereby  cause  a  contraction  in  their  walls  and 
diminution  of  their  calibre.  Upon  such  remedies 
much  reliance  might  be  placed.  Among  these  are 
found  the  mm*,  tiiict.  of  iron,  tinct.  of  belladonna, 
wine  of  ergot  and  others,  which  play  a  conspicuous 
part.  It  is  by  contracting  the  blood-vessels  to 
such  an  extent  that  a  sufficient  supply  of  blood 
cannot  be  transmitted  for  the  nourishment  of 
distant  tissues,  that  mortification  follows  the  too 
liberal  and  long-continued  use  of  ergot.  By  this 
property  of  producing  contraction  in  blood-ves- 
sels, uterine  hemorrhages  are  checked,  or  the 
action  of  the  grand  womb,  with  its  immensely 
developed  blood-vessels,  excited.  The  entire  pro- 
fession have  adopted  the  mur.  tinct.  of  iron  as 
nearly  a  specific,  against  the  fearful  inflammatory 
reaction  of  erysipelas;  for  stronger  reasons,  it  is 
equally  efficacious  in  simple  inflammatory  en- 
gorgements. Belladonna  shows  its  general  action 
by  dilating  the  pupil — an  effect  explained  by  the 
change  in  the  circulation  of  the  blood-vessels  of 
the  iris.  Its  advantages  in  relieving  injection  of 
the  blood-vessels  of  the  eye  are  well  known  and 
largely  used.  It  is  spoken  of  as  the  remedy  for 
the  rapid  relief  of  congestion  of  the  spinal  cord. 

16 


186  INTERNAL    TREATMENT    OF    WOUNDS. 

Although  these  are  the  individual  effects  of  such 
remedies,  they  are  not  the  specific  action  of  these 
medicines.  Their  influence  belongs  to  the  econ- 
omy, and  in  affecting  all  the  tissues,  those  feel 
their  influence  most  which  are  offending,  as  there 
would  be  the  widest  field  for  the  remedy  to  show 
its  common  effects. 

Inflammation  is  a  perverted  condition  of  the 
blood  and  blood-vessels  of  a  part,  which  means  a 
modified  state  of  nutrition.  There  are  two  dia- 
metrically opposed  means  of  correcting  this  con- 
dition and  restoring  health.  One  is,  by  reducing 
the  amount  of  blood  carried  to  the  part  which 
threatens  to  overwhelm  the  vital  functions  of  such 
an  inflamed  portion  of  the  body.  This  is  effected 
by  bloodletting,  vomiting,  purgation,  abstemious 
diet,  and  the  entire  list  of  depletory  or  spoliative 
remedies,  which  weaken  the  enemy  to  such  an 
extent  as  to  allow  of  the  part  attacked  success- 
fully coping  with  the  disease.  But  when  the 
disease  is  conquered,  the  victory  is  as  disastrous 
as  a  defeat,  a  long  convalescence  being  required 
to  restore  the  patient  to  his  former  state  of  health. 
The  other  method  is,  by  increasing  the  tone,  both 
of  part  and  system,  by  supporting  agents  which 
strengthen  the  garrison,  increase  the  vital  powers 
residing  within   the  tissues  for  resisting  the  en- 


INTERNAL    TREATMENT    OF    WOUNDS.  187 

croachments  of  disease,  and  thus  are  enabled  to 
drive  out  the  enemy,  however  violently  the  attack 
may  be  made.  These  successes  are  attained  with 
but  little  loss  on  the  part  of  the  system  which 
comes  out  of  the  fire  unscathed.  Our  object, 
then,  should  always  be  to  cure  disease  by  using 
such  remedies  as  will  cause  the  least  possible  loss 
to  the  economy. 

In  all  injuries,  were  it  not  for  an  exquisitely 
sensitive  nervous  system,  we  would  have  but  little 
systemic  sympathy,  and,  therefore,  but  little  per- 
sonal annoyance.  In  the  inferior  animals,  whose 
sensibilities  are  of  a  low  description,  limbs  can  be 
torn  oft*  without  deleterious  effect,  and  without 
producing  inflammation.  These  inflammatory 
tendencies  are  only  observed  as  we  advance  in 
the  scale  of  animal  life,  until  we  find  in  man  a 
perfection  of  a  nervous  system,  with  its  corres- 
ponding susceptibilities  to  physiological  as  well 
as  pathological  impressions.  If  we  could,  by 
some  metamorphosis  in  man,  temporarily  revert 
to  the  more  primitive  developments,  we  would 
diminish  the  dangers  of  local  trouble  ;  or  if  we 
could  take  possession,  as  it  were,  of  the  nervous 
functions  and  reduce  them  to  their  lowest  stage 
for  extending  sympathies,  we  could  equally  keep 
down   irritation,    and   to  a  great  extent  jugulate 


188  MORPHINE    ENDERMICALLY. 

the  tendency  to  establish  congestion  and,  subse- 
quently, inflammations. 

Opium,  by  which  we  can  effect  this  subjection, 
will  ever  be  the  greatest  boon  to  the  military  sur- 
geon ; — it  is  a  remedy  which  should  never  be 
absent  from  his  reach.  Going  on  the  field,  he 
should  have  his  pockets  well  stored  with  it  for 
immediate  use;  and  in  the  entire  treatment  of  the 
wounded  it  will  ever  hold  a  conspicuous  place. 
Morphine  is,  perhaps,  the  best  article  for  wound- 
ed men,  as  it  has  lost  in  preparation  some  of  its 
astringent  properties,  which,  as  opium  or  lauda- 
num, would  produce  too  great  a  tendency  to  con- 
stipation. 

The  endermic  method  of  using  this  remedy 
would  prevent  endless  suffering  on  the  battle 
field,  or  in  hospital  practice.  When  morphine  is 
taken  into  the  stomach,  it  is  dissolved  in  the 
fluids  there  found,  and  then  undergoes  absorp- 
tion. This  takes  place  with  greater  or  less  rapid- 
ity, according  to  the  nervous  excitement  under 
which  the  system  is  laboring.  At  times,  its  ab- 
sorption is  very  slow,  and  its  effects  upon  the 
system,  from  the  small  quantity  found  in  the  cir- 
culation, very  indifferent.  Under  other  circum- 
stances, very  large  doses  are  administered  in  vain, 
to  produce  the  soothing  effects  of  the  drug.     It 


MORPHINE    ENDER  MIC  ALLY.  189 

remains,  perhaps,  unchanged  in  the  stomach ; 
whilst  under  the  same  condition,  if  a  much 
smaller  dose,  in  solution,  be  injected  under  the 
skin  of  any  portion  of  the  body,  its  full  effects 
are  obtained  in  a  few  minutes.  The  following 
cases  will  show  the  marked  efficacy  of  the  remedy 
when  used  hypodermically : 

Mrs.  C.  had  been  operated  upon  for  cataract  by 
division  of  the  lens.  Violent  inflammation  ensued, 
ending  in  the  destruction  of  the  eye,  and  for 
three  days  she  suffered  agony;  day  and  night  she 
was  rolling  about  the  bed  in  spite  of  repeated 
doses  of  morphine.  Finding  that  one-half  grain 
every  two  or  three  hours  produced  no  alleviation 
of  her  suffering,  I  tried  the  experiment  of  injecting 
one-third  of  a  grain  under  the  skin  covering  the 
sternum.  A  Wood's  endermic  syringe  was  used; 
absorption  was  immediate;  in  two  minutes  she 
was  relieved ;  in  five,  all  pain  had  disappeared, 
and  in  ten  minutes  from  the  injection,  she  was 
sleeping  soundly  for  the  first  time  in  seventy 
hours. 

Mr.  M.  was  accidentally  shot  in  the  neck  with 
a  Colt's  pocket  revolver.  His  head  being  turned, 
the  ball  entered  the  skin  over  the  larynx,  coursed 
downward  and  backward  through  the  posterior 
triangle  of  the  neck,  and  was  found  under  the 


190  MORPHINE    ENDERMICALLY. 

skin  of  the  shoulder  over  the  spine  of  the 
scapula,  and  removed.  Considerable  swelling 
and  extravasation  followed,  which,  diffusing  it- 
self, discolored  that  side  of  the  neck.  Some  of 
the  brachial  plexus  of  nerves  must  have  been 
injured,  as  the  patient  was  soon  seized  with 
violent  pains,  shooting  down  toward  the  fingers, 
which,  although  never  altogether  absent,  would 
increase  to  torture  as  evening  advanced.  Toward 
morning  they  would  remit  and  allow  of  sleep, 
after  a  restless  and  painful  night.  Gum  opium 
and  morphine  in  large  doses  gave  him  no  relief. 
The  arm  was  so  sensitive  that  he  would  not 
permit  its  being  handled.  One-fourth  of  a  grain 
of  morphine  iu  three  or  four  drops  of  water  was 
injected  under  the  skin  of  the  shoulder;  in  five 
minutes  all  pain  had  left  him,  and  his  arm  could 
be  examined  rudely  without  the  slightest  suffer- 
ing. 

By  the  use  of  this  little  instrument,  a  new 
and  extensive  field  for  doing  good  is  open  to  the 
humane  military  surgeon,  and  he  who  is  the  fortu- 
nate possessor  of  this  talisman,  will  receive  daily 
the  thanks  and  blessings  of  his  suffering  patients. 
When  chloroform  cannot  be  obtained,  I  would 
suggest  this  mode  of  blunting  sensibility,  imme- 
diately before  operations  are  performed  or  pain- 


MORPHINE    ENDERMICALLY.  191 

ful  and  tedious  dressings  are  made.     It  will  be 
found  a  good  substitute,  and  one  which  will  yield 
its   full  effects  without  delay  or   trouble.     There 
are  very  few  injuries  requiring  operation  which  do 
not  demand  the  free  use  of  opium.     Narcotising 
the  patient  immediately  before  the  operation,  and 
keeping  him  under  its  influence  for  some  hours,  is 
among   the  best  means  of  preventing  an   excess 
of  reaction.     The  rapidity  of   action  when  mor- 
phine is  used  endermically  is  a  very  great  advan- 
tage  on    the    field,    where    every   moment   is    of 
value.     For   complete    narcotism,   where    a   suffi- 
cient quantity  of  morphine  is  used,  five  minutes 
are  all  that  is  required;   whilst  with  chloroform 
we   all   know   that,   when   under   excitement,   its 
inhalation  is  often  extended  from  thirty  to  sixty 
minutes,  and  even  longer— time  which  the  field 
surgeon  can  ill  spare! 


CHAPTER    VI. 

Complications  which  arise  during  the  treatment  of  gun- 
shot wounds — Erysipelas,  contagious  and  infectious 
character — Constant  tendency  to  debility — Treat- 
ment, general  and  local — Pyaemia,  a  rare  disease  in 
our  country;  symptoms — Theory  of  mult i pled  ab- 
scesses—  Great  remedy;  Prevention  by  rigid  observ- 
ance of  hygienic  regulations  —  Local  and  general 
treatment — Hospital  Gangrene,  its  appearance*, 
how  recognized;  causes  giving  rise  to  it — Thorough 
ventilation  necessary  to  successful  treatment — Local 
applications,  actual  cautery,  etc. — Tetanus  charac- 
ters; march — Rarity  of  cure  in  military  surgery — 
Local  and  general  treatment  upon  which  most  reli- 
ance can  be  placed — Woorara  in  Tetanus — Hectic, 
from  long-continued  suppuration — Permanent  and 
Periodic  Pains. 

Erysipelas. — We  have  already  entered,  in  de- 
tail, into  the  causes  of  secondary  hemorrhage, 
which  is  one  of  the  most  alarming-  complications 
that   can   befal   the  wound.      A   second,    that    is 


ERYSIPELAS.  193 

to  both  surgeon  and  patient,  is  erysipelas.  This 
disease  appears  to  revel  in  the  depressing  influ- 
ences which  follows  armies,  and  sometimes,  as  an 
epidemic,  attacks  all  wounds,  ravages  limbs,  and 
makes  its  heaps  of  victims.  For  several  years, 
particularly  during  the  winter  months,  erysipelas 
has  appeared,  at  times,  even  as  an  epidemic  in  the 
States,  especially  in  the  middle  region  of  country. 
Our  troops  can,  therefore,  hardly  be  expected  to 
escape  its  ravages.  Although  it  frequently  occurs 
as  an  idiopathic  disease,  its  most  frequent  excit- 
ing cause  is  a  wound. 

Gunshot  wounds  in  patients  debilitated  by  the 
many  depressing  influences  of  camp  life,  are  pecu- 
liarly prone  to  attacks  of  erysipelas.  The  variety 
more  frequently  met  with  among  troops  is  the 
phlegmonous,  or  as  it  is  now  called,  the  cellulo- 
cuxaneous  variety.  It  makes  its  appearance  with 
violent  inflammatory  symptoms,  intense  swelling, 
tension,  redness,  pain,  heat,  and  effusion.  It 
extends  rapidly  from  the  wound  as  a  centre,  and 
soon  covers  a  large  area,  accompanied  by  symp- 
toms of  inflammatory  fever,  with  dirty,  foul 
tongue,  and  deranged  gastrio-intestinal  secretion. 
It  will  be  remarked  that  the  pulse,  although  fre- 
quent and  full,  has  no  strength,  and  general  pros- 
tration ensues  at  a  very  early  day.  Often  by  the 
17 


194  ERYSIPELAS. 

fourth  day  the  hardened  (Edematous  tissue  already 
feels  boggy,  indicating  the  extensive  formation  of 
pus  and  sloughs  under  the  skin.  The  wound 
usually  gives  outlet  to  these  at  an  early  day.  But 
as  the  disposition  of  the  disease  is  not  to  localize 
itself,  the  active  effusion  thrown  out  in  the  extent 
of  tissues  undergoes  a  pusy  conversion,  which 
leaves  this  matter  disseminated  in  all  the  tissues 
where  the  effusion  had  been  poured  out.  It  is  in 
this  manner  that  the  extensive  purulent  dissection 
of  limbs  takes  place ;  when  the  muscles  are  isola- 
ted, blood-vessels  separated  from  the  surrounding 
connections,  bones  exposed  from  their  periostium, 
and  joints  opened,  a  general  destruction  of  cellu- 
lar tissue  ensues.  Shreds,  or  layers  resembling 
strips  of  wet  chamois  leather  may  be  pulled 
away.  The  extensive  loss  of  support  to  the 
skin  causes  it  to  break  down  in  sloughs,  which 
makes  a  vent  for  the  escape  of  this  accumulat- 
ing fluid.  Nature,  in  its  weakened  condition, 
cannot  stand  this  drain  of  its  best  nutrient  mate- 
rial; and  prostration,  feeble,  irregular  pulse,  dry 
tongue,  diarrhoea,  delirium,  and  finally  coma,  ends 
the  scene.  Or,  should  judicious  treatment  check 
its  inroads,  a  tedious  convalescence  and  a  shat- 
tered constitution  remains  to  the  patient. 

Erysipelas  can  always  be  recognized  by  its  dis- 


ERYSIPELAS.  195 

tinctive  characters  of  widely  extended  local  in- 
flammation, with  tendency  to  rapid  suppuration 
and  sloughing  of  the  wound. 

The  prognosis  of  this  complication  is  always 
serious,  when  it  occurs  after  gunshot  wounds, 'in 
military  surgery,  because  the  constitutions  of 
the  patients  have  been  undermined,  to  a  certain 
degree,  by  the  hardships  and  irregularities  which 
all  soldiers  in  time  of  war  must  submit  to. 

In  the  treatment  of  gunshot  wounds  it  must  be 
remembered,  that  erysipelas,  which  is  a  very  fatal 
complication,  is  often  produced  by  a  careless  dis- 
regard of  those  hygienic  regulations  which  are  so 
essential  in  the  proper  organization  of  a  hospital. 
Over-crowding,  bad  ventilation*  want  of  cleanli- 
ness, are  constant  causes  for  its  production  and 
propagation.  As  the  disease  is  clearly  contagious 
as  well  as  infectious,  the  directors  of  military 
hospitals  must  be  very  careful  how  they  permit  a 
case  of  erysipelas  to  be  introduced  into  a  ward 
with  wounded  men;  for  inoculation  will  at  once 
ensue,  and  when  erysipelas  has  taken  possession 
of  a  ward,  it  is  with  great .  difficulty  eradicated. 
Its  effects  can  be  traced  first  upon  contiguous 
patients,  whose  wounds,  healing  kindly  prior  to 
the  introduction  of  this  focus  of  contamination, 
now  take  on  erysipelas.     The  system  soon  shows 


19G  ERYSIPELAS. 

the  depression  under  which  the  patient  is  labor- 
ing. Some  further  complication,  with  low  visce- 
ral inflammation  of  either  the  memhranes  of  the 
brain  or  lungs  or  intestinal  surface  ensues,  and 
life  is  overwhelmed  by  this  combination. 

Erichsen,  in  his  Science  and  Art  of  Surgery, 
mentions  the  following  case  in  proof  of  the  con- 
tagion of  erysipelas,  as  having  occurred  in  one  of 
his  wards  at  University  College  Hospital.  "The 
hospital  had  been  free  from  any  cases  of  this 
kind  for  a  considerable  time,  when,  on  the  15th 
Januaiy,  1851,  at  about  noon,  a  man  was  admitted 
under  my  care,  with  gangrenous  erysipelas  of  the 
legs,  and  placed  in  the  ward.  On  my  visit  two 
hours  after  his  admission,  I  ordered  him  removed 
to  a  separate  room,  and  directed  the  chlorides  to 
be  freely  used  in  the  ward  from  which  he  had 
been  taken.  Notwithstanding  these  precautions, 
however,  two  days  after  this,  a  patient,  from 
whom  a  portion  of  necrosed  ilium  had  been 
removed  a  few  weeks  previously,  and  who  was 
lying  in  the  adjoining  bed  to  that  in  which  the 
patient  with  the  erysipelas  had  been  temporarily 
placed,  was  seized  with  erysipelas,  of  which  he 
speedily  died.  The  disease  then  spread  to  almost 
every  case  in  the  ward,  and  proved  fatal  to  sev- 
eral  patients   who    had    been    recently   operated 


TREATMENT    OF    ERYSIPELAS.  107 

upon."  If  such  be  its  tendency  in  civil  hospitals, 
how  frightful  will  its  march  be  among  the  wound- 
ed in  military  hospitals.  Such  cases  should  be 
kept  exclusively  to  themselves,  or  they  entail 
incalculable  loss  upon  the  wounded. 

The  antiphlogistic  treatment  of  erysipelas,  espe- 
cially the  phlegmonous  variety  which  we  are  now 
considering,  has  for  many  years  been  abandoned ; 
and  he  who  attempts  to  cure  erysipelas  in  military 
surgery  by  depressing  agents,  will  pa}T  heavily  for 
his  rashness.  However  violent  its  symptoms  are, 
the  surgeon  must  not  be  deceived.  It  is  a  disease 
of  marked  debility :  its  violent  attack  is  only  a 
mask  to  be  thrown  off  in  a  few  days,  and  often  in 
a  few  hours.  \\rheu  the  plan  of  attack  is  so  well 
known,  as  it  is  in  erysipelas,  where  a  study  of  the 
natural  history  of  the  disease  has  invariably 
shown,  in  its  march,  certain  and  speedy  prostra- 
tion, the  surgeon  is  highly  culpable  who  does  not 
commence  with  the  earliest  treatment  to  build  up 
and  support  the  system,  and  thus  prepare  it  to 
withstand  the  depression  which  is  so  sure  to 
ensue,  and  which,  if  overlooked,  will  be  so  fatal. 

Prevention  is  always  more  judicious  than  cure, 
and,  therefore,  our  first  care  should  be — by  the 
strict  observance  of  those  hygienic  regulations 
for  ventilation  and  cleanliness,  and  against  over- 


198  TREATMENT    OF    ERYSIPELAS. 

crowding — to  keep  the  wards  of  an  hospital  with 
so  pure  an  atmosphere  as  to  give  no  encourage- 
ment for  this  low  class  of  diseases  to  intrude 
themselves.  When  a  case  appears,  isolate  it  at 
once,  and  use  every  precaution  against  contagion. 
The  sponges,  bandages,  etc.,  used  by  this  patient, 
should  be  confined  exclusively  to  himself;  for  if 
the  same  sponge  be  used  for  a  dozen,  they  would 
all  be  as  surely  inoculated.  Fresh  air  is  indis- 
pensable in  the  successful  treatment  of  this  dis- 
ease. Leave  all  the  windows  open  for  thorough 
ventilation,  running  the  risk  of  catarrhal  affec- 
tions, which  are  trivial  when  compared  to  the 
serious  character  of  the  disease  under  discussion. 
The  treatment,  ever  having  in  view  the  steady, 
onward  march  of  the  disease  to  suppuration, 
sloughing,  and  prostration,  unless  a  barrier  is 
thrown  across  its  path,  should  be  from  the  com- 
mencement stimulating  and  supporting.  This 
tonic  course  is  prefaced  by  some  mild  cathartic 
to  cleanse  the  bowels  of  impurities  which  rapidly 
accumulate  in  them,  and  excite  healthy  secretions 
from  the  digestive  organs.  For  this  purpose,  the 
comp.  colocynth  pill  would  be  a  good  prescrip- 
tion,  although  a  dose  of  castor  oil  or  sulph. 
magnesia,  would,  in  the  majority  of  cases,  fill 
every  indication.     Without  waiting  the  action  of 


TREATMENT    OF    ERYSIPELAS.  199 

this  cathartic,  which  is  expected  to  have  only  a 
moderate  effect,  we  at  once  prescribe  what  is  now 
called  the  specific  by  many,  and  recognized  as 
useful  by  all,  the  tincture  of  the  muriate  of 
iron,  thirty  minims,  in  a  wineglass  of  water, 
every  three  hours.  Besides  acting  as  a  general 
tonic,  and  also  through  its  mineral  acid  upon 
the  liver,  promoting  biliary  secretion,  it  affects 
directly  the  blood-vessels,  producing  contraction 
in  their  walls,  and  a  diminution  of  their  calibre, 
relieving  congestion,  and  preventing,  to  a  great 
extent,  effusions.  I  have  seen  it  cut  short  a 
traumatic  erysipelas  of  the  face  after  an  exten- 
sive operation  for  cheiloplasty,  in  thirty-six  hours 
from  its  appearance. 

In  connection  with  the  mur.  tine,  of  iron,  and 
of  equal  importance  with  it,  is  brandy  and  nour- 
ishment. Erichsen  says:  "I  have  seen  the  best 
possible  results  follow  the  free  administration  of 
the  brandy  and  egg  mixture,  to  which  I  am  in 
the  habit  of  trusting  in  the  majority  of  these 
cases."  Its  liberalise  will  restore  strength,  soft- 
en the  tongue,  and  remove  delirium.  When  the 
skin  is  dry  and  harsh,  mild  diaphoretics  should  be 
us?d,  and  as  anodynes  are  always  required  in  the 
treatment  to  allay  pain  and  to  give  sleep,  Dovers' 
powdeTs  would  be  a  valuable  agent.     By  adopting 


200  TREATMENT    OF    ERYSIPELAS. 

this  course  of  attending  to  the  secretions,  keeping 
the  howels  soluble,  and  supporting  the  system, 
even  from  the  very  commencement  against  that 
prostration  which  is  certain,  sooner  or  later,  to 
show  itself,  this  scourge  in  military  hospitals 
will  he  most  successfully  controlled. 

Considering  the  disease  as  one  of  marked  de- 
bility, most  reliance  should  be  placed  upon  the 
general  treatment.  All  local  applications  should 
tend  to  relieve  engorgement.  In  the  early  inflam- 
matory stage,  before  suppuration  is  established, 
painting  the  limb  with  the  per  chloride  of  iron, 
or  a  dilute  tincture  of  iodine,  or  using  compresses 
soaked  with  tincture  of  arnica,  etc.,  would  tend 
to  promote  healthy  action.  Cold  water,  by  irriga- 
tion, or  iced  applications,  would  be  as  useful  here 
as  in  any  other  engorgements.  All  of  these 
applications  may  be  accompanied  with  the  me- 
thodically applied  roller,  which  will  compress 
the  limb,  and  by  its  mechanical  support  prevent 
infiltration  and  congestion,  and  relieve  tension 
and  swelling.  Sugar  of  lead  lotions  are  highly 
lauded.  Free  incisions  are  recommended  by 
man}-  surgeons  to  relieve  the  engorged  vessels. 
They  give  great  relief  to  the  patient,  but  it  is  a 
question  whether  they  do  not  increase  the  irrita- 
tion and  hasten  the    suppurative  stage,  an  effect 


PYAEMIA.  201 

not  to  be  desired,  as  the  entire  armamentarium  of 
the  surgeon  is  directed  against  the  formation  of 
pus. 

When  pus  has  formed,  which  will  be  recognized 
by  the  doughy  sensation  of  the  parts  into  which 
the  fingers  sink  when  pressure  is  made,  and  a 
little  later  by  fluctuation,  incisions,  sufficiently 
free  to  admit  of  the  ready  escape  of  pus,  should 
be  made,  and  stimulating  water  dressings  con- 
tinued to  hasten  the  elimination  of  the  sloughs, 
and  diminish  the  amount  of  secretion.  The 
tincture  of  arnica,  or  spirits  of  camphor,  or  La- 
barraque's  chloride  of  soda,  diluted  with  from 
six  to  ten  parts  of  water,  or  diluted  tincture  of 
iodine,  make  an  excellent  stimulating  application. 
"Wherever  pus  shows  a  disposition  to  bag,  it 
should  be  let  out  by  incisions.  As  the  skin, 
largely  undermined,  is  disposed  to  slough  ex- 
tensively, it  should  be  supported  by  properly 
applied  bandages,  which,  by  diminishing  the  cav- 
ity within,  will  prevent  burrowing  of  pus,  and 
cause  the  skin  to  adhere  to  the  deeper  parts  as 
soon  as  adhesive  action  can  be  excited. 

Pycemia,  a  disease  very  common  in  Europe,  and 
a  scourge  of  their  military  hospitals,  is  a  disease 
but   little   known    among   us,   and   therefore   not 


202  PYiEMIA. 

likely  to  attack  our  wounded,  unless  we  neglect 
necessary  hygienic  precautions.  When  it  shows 
itself  in  a  hospital,  like  its  kindred  disease  erysip- 
elas, it  is  not  satisfied  until  it  has  swept  off  its 
hundreds,  and  is  a  pest  hard  to  be  got  rid  of. 
The  great  similarity  in  causes,  symptoms  and 
effects,  are  sufficient  grounds  for  associating  this 
with  the  large  class  of  asthenic  diseases,  among 
which  erysipelas  and  hospital  gangrene  are  promi- 
nent. It  is  impossible  to  control  the  symp- 
toms and  prevent  a  fatal  issue,  when,  as  acute 
pysemia,  it  seizes  upon  the  wounded  in  military 
hospitals;  it  is  therefore  much  more  to  be  feared 
than  its  kindred  disease  just  mentioned.  Al- 
though this  disease  is  always  associated  with 
wounds,  no  wound,  however  trivial,  or  however 
.  well  advanced  toward  cicatrization,  is  safe  from 
its  attack  until  completely  healed.  The  dis- 
ease is  supposed  to  be  caused  by  the  absorption 
of  the  ichorous  fluids  decomposing  in  the  wound, 
which  produces  a  general  poisoning  of  the  blood, 
rendering  it  unfit  for  sustaining  the  economy.  It 
has  been  ealled  an  acute  decomposition  of  the 
blood. 

The  phenomena  which  accompany  this  af- 
fection are,  great  depression  of  the  powers  of 
the   system,    and   the   formation    of  abscesses   in 


PYEMIA.  203 

various  parts  of  the  body.  In  the  prodrome, 
which  may  precede  the  explosion  of  the  disease 
by  twenty-four  or  thirty-six  hours,  the  patient  is 
restless,  anxious,  ill  at  ease,  with  forebodings  of 
impending  trouble.  He  looks  pale  and  sallow,  has 
loss  of  appetite,  and  generally  deranged  secre- 
tions. The  disease  commences  by  severe  chills, 
which,  in  the  acute  cases,  are  repeated  with  much 
irregularity.  In  the  subacute  variety,  these  chills 
appear  at  such  regular  intervals,  followed  by 
high  fever  and  terminating  in  profuse  sweats,  as 
to  induce  the  belief  of  malarial  fever.  In  many 
cases  the  skin  is  hot,  with  a  pungent  feel,  irre- 
spective of  the  chills;  in  others,  the  chilly  and 
feverish  sensations  alternate.  The  pulse  is  feeble ; 
face  pale,  with  anxiety  of  countenance  and  ten- 
dency to  delirium ;  tongue  foul,  a  tendency  for 
sordes  to  collect  on  the  teeth,  and  the  tongue  to 
become  dry;  stomach  uneasy,  with  bilious  vomit- 
ing, and  thirst  constant.  The  suspension  of  secre- 
tions gives  a  dull  yellowish  icteric  tint  to  the  skin. 
As  the  pulse  becomes  more  and  more  enfeebled, 
the  patient  may  complain  of  pains  in  his  joints, 
simulating  rheumatism,  and  simultaneous  with 
these,  a  reddening  of  the  skin,  with  swelling  of  the 
joints.  Collections  of  a  pusy  character  will  soon 
after  be  detected,  distending  the  synovial  sacks. 


204  PYEMIA. 

Collections  also  occur  in  the  cellular  tissue, 
and  even  in  the  substance  of  organs.  These 
form  rapidly  and  without  much  inconvenience. 
Often,  the  swelling  alone  —  which  has  appeared 
during  the  night,  unaccompanied  with  pain,  red- 
ness or  heat — indicates  that  a  large  collection  of 
pus  has  already  taken  place. 

Whilst  these  symptoms  progress,  the  wound 
usually  becomes  foul  and  sloughy,  ceasing  to 
secrete  pus.  This  is  not  the  invariable  rule,  as 
surgeons  have  noticed  cases  in  which  the  appear- 
ance of  the  wound  was  no  indication  of  the 
destructive  disease  which  had  laid  its  relentless 
hand  upon  the  injured.  The  disease  may  even 
run  its  fatal  course  without  material  changes  in 
the  wound.  Certain  injuries  are  more  likely  to 
be  followed  by  pyremia,  and  those  of  bone  are 
said  to  be  peculiarly  exposed.  As  in  all  such 
low  diseases,  typhoid  symptoms  ensue  at  an  early 
day,  and  usually  carry  off  the  patient  at  the  end 
of  the  first  week.  Often  stupor  comes  on  as  early 
as  the  fourth  day.  An  examination  after  death 
will  reveal  a  rapidly  advancing  decomposition, 
with  gas  in  the  blood-vessels,  and  purulent  col- 
lections in  many  organs,  as  the  lungs,  liver, 
spleen,  kidneys,  heart  and  brain.  Similar  collec- 
tions are  found  in  most  of  the  large  joints,  be- 
side the  multiplied  abscesses  of  the  cellular  tissue. 


PYJEMIA.  205 

The  theory  of  the  metastatic  character  of  the 
abscesses,  or  the  sudden  change  of  place  of  such 
deposits  by  absorption  and  redeposit  has  long 
been  abandoned.  Pus,  we  now  know,  to  be  a 
modified  nutrient  fluid,  which,  from  an  impair- 
ment of  its  vitalizing  principle,  falls  short  of  its 
object  of  repairing  tissues.  This  exudation  leaves 
the  blood-vessels  under  ordinary  acute  inflamma- 
tion, and  is  drawn  out  by  the  excited  tissues 
which  are  not  able  to  consume  the  excess 
which  the}"  have  demanded  from  the  circulation. 
This  fluid,  now  at  rest  without  the  blood-vessels, 
attempts  a  formation  of  its  own,  developing  cells 
of  this  plasma,  which  simulate  closely  the  white 
cells  in  the  progressive  development  of  the  blood, 
and  are  supposed  by  some  pathologists  to  be 
identical  with  them.  This  is  pus.  When  the 
entire  circulating  fluid  has  become  poisoned,  its 
entire  plasma  or  liquor  sanguinis  is  impaired.  It 
is  from  this  plasma  that  the  blood-cells  are  to  be 
generated.  The  usual  process  of  development  is 
commenced,  white  cells  form  as  colorless  blood 
corpuscles,  and  when  the  continued  development 
into  the  red  or  perfect  cell  is  attempted,  many 
failures  occur.  There  are,  besides,  many  which 
had  exhausted  their  formative  powers  in  attain- 
ing   the    degree    of    development    necessary    to 


•   206  PYiEMIA. 

perfect  the  white  cell.  These  remaining  as  such 
continue  in  the  circulation.  When  the  blood  of 
a  pyamiic  patient  is  examined,  a  very  large 
number  of  such  colorless  cells  are  found  in  the 
blood,  sufficient  to  modify  its  color,  and  it  is  in 
autopsies  that  the  separation  of  these  white  cells 
from  the  generating  fluid  shows  the  deceptive 
appearance  of  pus  in  the  blood,  or  emboli  in 
the  large  vessels  at  the  heart. 

Blood  in  this  condition,  with  an  impaired 
liquor  sanguinis,  is  unfit  for  its  duties  as  a 
life-supporting  fluid.  The  various  tissues  of 
the  body,  not  receiving  the  kind  of  nourish- 
ment appropriate  for  their  healthy  function,  be- 
come irritated.  Nature  tries  to  make  up  the 
deficiency  in  quality  by  quantity.  The  irritated 
parts  are  supplied  with  an  excess  of  the  impaired 
nutritive  fluid,  which,  escaping  from  the  capil- 
laries, is  received  into  the  loose  tissues.  This  is 
rapidly  converted  into  pus,  by  the  development  cr 
white  or  colorless  cells  in  it,  which  is  the  height 
of  vitality  in  such  an  exudate. 

Experience,  which  sustains  this  view,  shows 
the  disease  to  be  purely  a  blood  poisoning ;  a  gen- 
eral disease  with  its  local  manifestations,  which 
are  unimportant.  When  the  blood  has  been  thus 
thoroughly   deteriorated,    no    remedy   which    art 


PYAEMIA.  207 

possesses  can  restore  it  to  its  former  healthy 
condition,  and  the  patient  dies. 

Our  great  remedy  lies  in  prevention,  the  hygi- 
enic precautions  of  rigid  cleanliness,  thorough 
ventilation,  good  food,  and  proper  shelter,  without 
over-crowding,  will,  if  properly  insisted  upon  by 
the  medical  superintendent,  go  far  to  keep  away 
if  they  do  not  altogether  prevent  the  occurrence 
of  pyaemia.  Too  much  attention  cannot  be  paid 
to  the  detail  of  cleanliness  in  the  ward.  The 
slop  buckets,  which  are  such  a  common  nui- 
sance, should  be  examined  with  care,  frequently 
emptied,  scoured  daily  with  lime,  and  always 
kept  covered,  that  the  emanations  arising  from 
decomposing  urine,  which  is  very  deleterious  in 
hospital  wards,  cannot  escape.  The  bed  and  body 
linen  of  the  patients  should  be  daily  changed, 
doors  and  windows  must  be  kept  open.  If  any 
difficulty  exists  in  this  respect,  from  the  inatten- 
tion of  nurses  or  fears  of  patients,  it  would  be 
better  to  take  out  the  sashes  so  as  to  ensure 
continued  renewal  of  the  atmosphere,  day  and 
night. 

There  is  a  popular  dread  of  night  air  which 
should  be  exploded.  The  purest  air  we  have  in 
cities  is  the  night  air,  and  is  the  very  article 
which  is  so  much  needed  in  hospitals.     If  the  pa- 


208  PYAEMIA. 

tient  is  properly  covered  in  bed,  there  is  no 
fear  of  his  taking  cold,  or  contracting  other 
injury  from  the  continued  renewal  of  pure 
air.  These  precautions  must  not  be  commenced 
when  pyaemia  has  already  shown  itself,  but  are 
those  necessary  to  be  taken  wherever  the  serious- 
ly wounded  are  treated,  or  some  low  form  of  dis- 
ease will  soon  break  out.  Any  one  who  will  visit, 
during  the  night,  a  ward  filled  with  suppurating 
wounds,  will  perceive  the  degree  of  vitiated  air, 
and  see  the  necessity  for  free  ventilation. 

It  is  a  bad  principle  to  concentrate  the  seriously 
wounded;  always  scatter  them  over  the  building, 
mixing  them  in  with  inmates  from  other  diseases. 
This  increases  the  available  space  for  the  seriously 
wounded,  and  prevents  the  depressing  effect  of 
the  concentrated  emanations  from  so  many  exten- 
sively suppurating  wounds.  It  is  for  a  similar 
reason  that  we  have  already  recommended  that 
rooms  should  not  be  kept  too  long  in  use  when 
occupied  by  the  severely  wounded.  As  the  air 
becomes  poisoned,  the  ward  requires  to  be  un- 
occupied two  weeks  of  every  two  months,  for 
cleansing  and  purification. 

When  pyaemia  threatens  to  become  general 
in  a  military  hospital,  the  seriously  wounded 
should  be  put,  if  possible,  in  tents,  or  be  allowed 


PYEMIA.  2U9 

double  space  in  a  constantly-ventilated  room,  and 
an  additional  quantity  of  nourishing  food  should 
be  given  out  to  the  sick.     Feeding  the  wounded 
on  broths  and  other  slops,  is  paving  the  way  to 
the  debility  which  is  a  precursor  of  pyaemia.     All 
small  operations  should  be  avoided,  and  even  the 
hasty  opening  of  abscesses  guarded  against.     The 
best   protection    against    this    disease   is   a  whole 
skin.     When  the  acute  form  of  the  disease  shows 
itself,    suro-erv    can    do    but    little   to    assist   the 
patient.     If  it  be   possible,  more  benefit  will  be 
derived  from  changing  the  patient  into  fresh  air 
than  from  auy  other  remedy.      Our  entire  reliance 
should   be   placed    upon   the    stimulating   tonics. 
Strong,  nutritious,  easily  digested  food,  and  opium 
to  allay  pain  and  restlessness,  are  the  means  re- 
quired.     The   tendency   to    delirium    should  not 
prevent   the    free    use   of   this    last    remedy,    for 
although  it  would  increase  the  difficulty  if  it  be 
given  in  inflammation  of  the  brain  or  meninges, 
it  allays  pain,  removes  restlessness,  stops  mutter- 
ing, and  induces  quiet  sleep,  when  given  in  cases 
of  debility  accompanied  by  delirium.     As  in  ery- 
sipelas the  acid   preparations  of  iron,  as  a  blood 
tonic,  may  be  exhibited. 

Although    so    little   is   to    be   expected   in   the 
acute  form  of  blood  poisoning,   in   the    subacute 
18 


210  HOSPITAL   GANGRENE. 

or  chronic  pysemia,  much  benefit  will  be  derived 
from  rigidly  pursuing  the  course  of  treatment 
just  marked  out.  By  the  stimulating  and  sup- 
porting plan,  with  change  of  air,  many  patients, 
after  a  long  struggle,  may  be  saved. 

The  important  indication  for  local  treatment  in 
pyaemia  is  to  prevent  the  accumulation  of  putres- 
cent fluids  in  the  wound  by  cleanliness — and  the 
frequent  application  of  chlorinate  washes,  which 
remove  fcetor  and  stimulate  the  granulating  sur- 
face. The  abscesses  which  form  during  the 
march  of  the  disease,  should  not  be  too  hastily 
opened,  as  this  course,  pursued  with  the  many 
collections,  will   induce  rapid  prostration. 

Still  another  fatal  complication  to  which  gunshot 
wounds  are  liable,  is  hospital  gangrene,  the  name 
being  significant  of  the  cause  of  this  pest,  as  it 
is  never  seen  as  an  isolated  disease  without  the 
crowded  w  ards  of  a  hospital.  It  is  highly  prob- 
able that,  like  the  former  diseases  which  we  have 
just  considered,  it  is  a  blood  poisoning,  depending 
upon  a  foul,  infected  atmosphere,  operating  upon 
a  depraved  and  enfeebled  constitution.  It  seldom 
attacks  the  strong  aud  robust,  but  most  frequently 
those  who  have  become  debilitated  by  exposure, 
disease,  want  of  proper  food,  intemperance,  etc. ; 
so    that   in    a   crowded  hospital,   when   gangrene 


HOSPITAL    GANGRENE.  211 

threatens  to  devastate  the  wards,  you  might 
select,  in  advance,  the  cases  which  will  most 
probably  be  first  attacked.  Many  surgeons  con- 
sider it  a  constitutional  disease,,  occurring  from 
a  strictly  local  cause,  which  is  found  within  the 
walls  of  the  hospital.  All  surgeons  recognize 
its  contagious  as  well  as  infectious  character, 
and  the  facility  of  transmitting  it  by  sponges  or 
dressings  used  in  common  in  a  ward. 

The  facility  with  which  the  air  of  a  ward  or 
even  hospital  becomes  impregnated  with  this 
poison,  would  show  that  animal  exhalations,  espe- 
cially from  those  suffering  under  this  disease, 
possess  the  power  of  diffusing  it.  Burgman 
reports,  that  hospital  gangrene  prevailed  in  one 
of  the  low  wards  at  Leyden,  whilst  the  ward  or 
garret  above  it  was  free.  The  surgeon  made  an 
opening  in  the  ceiling  between  the  two,  in  order 
to  ventilate  the  lower  or  affected  ward,  and  in 
thirty  hours  three  patients  in  the  upper  room, 
who  lay  next  the  opening,  were  attacked  by  the 
disease,  which  soon  spread  through  the  whole 
ward. 

Guthrie,  confirms  the  above  by  his  experience, 
which,  he  says,  left  no  doubt  upon  the  mind  of  any 
one  who  had  frequent  opportunities  of  seeing  the 
disease,  that  one  case  of  hospital   gangrene  was 


212  APPEARANCES    OF    HOSPITAL    GANGRENE. 

capable  of  infecting  not  only  every  ulcer  in  the 
ward  but  in  every  ward  near  it,  and  ultimately 
throughout  the  hospital,  however  extensive  it 
may  be. 

■  Both  English  and  French  surgeons,  in  the  Cri- 
mean war,  recognized  the  atmosphere  as  clearly 
the  vehicle  of  its  extension,  and  that  its  increase 
or  diminution  depended  upon  the  crowded  condi- 
tion of  the  wards  and  the  degree  of  ventilation. 
They,  also,  observed  the  certainty  with  which  it 
increased  when  the  same  sponges  were  used  for 
gangrenous  and  healthy  wounds.  It  may  be  con- 
sidered a  thoroughly  contagious  disease. 

Those  who  observe  the  march  of  the  healing 
process  of  wounds,  within  and  without  hospitals, 
know  how  easily  the  one  is  cured,  and  with  what 
difficulty  a  tedious  cure  is  obtained  in  the  other. 
Where  the  exhalations  from  many  suppurating 
wounds  are  concentrated  in  a  ward,  the  cicatriza- 
tion of  all  wounds,  even  the  most  simple,  are 
retarded,  and  contagion  of  any  kind  readily  pro- 
pagated. 

In  military  hospitals,  hospital  gangrene  will  be  recog- 
nized by  the  following  appearances  :  Although  the 
patient  may  have  recently  shown  feverish  symp- 
toms, with  loss  of  appetite,  yellowish  or  pale 
skin,    dirty   tongue,    and    deranged    bowels,    the 


APPEARANCES    OF    HOSPITAL    GANGRENE.  218 

first  appearance  of  the  disease  is  recognized  in  the 
changes  which  the  wound  undergoes,  which  has 
led  many  to  believe  it  to  be,  at  first,  a  local  dis- 
ease, in  time  infecting  the  system.  The  granulat- 
ing surface  of  a  healthy  sore,  about  taking  on  this 
sloughing  phagedena,  becomes  dry  and  painful. 
The  florid  hue  of  the  granulations  rapidly  disap- 
pear, and  is  replaced  by  a  dirty  gray  or  ash-colored 
slough,  which  fills  the  wound  and  forms  a  pulta- 
ceous  and  adherent  covering  to  the  granulating 
surface.  As  this  gray  slough  increases  in  extent 
and  depth,  the  surrounding  surface  becomes  cedem- 
atous,  swollen  and  of  a  livid  red  or  purplish  color. 
This  engorged  appearance  of  the  contiguous  skin 
always  precedes  the  advance  of  the  gray  slough. 
The  edges  of  the  ulcer  are  abruptly  cut,  under- 
mined and  everted,  gradually  assuming  a  circular 
outline,  irrespective  of  the  form  of  the  wound  prior 
to  its  invasion.  The  gray,  tenacious  mass,  being 
formed  of  the  mortified  tissue,  holds  its  place 
and  cannot  be  wiped  off,  although  it  sways  to 
and  fro  when  any  attempt  is  made  to  cleanse  the 
wound. 

The  liquefaction  of  these  mortified  tissues  soon 

commences,  and  a  dirty,  thick,  highly  offensive, 

irritating  fluid,  produced  from  the  putrefaction  of 

•  the  slough,  escapes  from  the  wound,  diffusing  a 


214  APPEARANCES    OF     HOSPITAL    GANGRENE. 

peculiar  odor  which,  when  once  smelt,  will  always 
be  recognized.  This  is  the  poison  which  pos- 
sesses such  powers  of  infection  when  brought  in 
contact  with  healthy  wounds. 

Once  the  disease  has  fairly  rooted  itself,  its 
ravages  are  extensive  and  rapid.  One  can  nearly 
see  the  extending  line  of  slough,  and  often  in 
twenty-four  hours  large  portions  of  the  skin, 
cellular  tissue,  and  muscles  will  have  mortified. 
These  changes  in  the  wound  are  accompanied  by 
a  severe  burning,  stinging,  lancinating  pain. 

Pari  passu  with  this  local  destruction  the  system 
is  gradually  or  rapidly  showing  the  influence  of  the 
poison.  Although  the  symptoms  may  be  at  first 
of  an  inflammatory  character,  accompanied  b}T  a 
high  fever,  the  pulse  soon  loses  its  strength,  the 
mind  is  peevish,  fretful  and  desponding,  the 
tongue  becomes  dry  and  brown.  The  pain 
accompanying  these  changes  is  so  severe  as  to 
deprive  the  patient  of  sleep.  As  the  febrile 
accompaniments  of  the  disease  rapidly  assumes  a 
typhoid  cast,  delirium  ensues  and,  with  a  ten- 
dency to  coma,  becomes  a  prominent  symptom. 

Should  the  case  not  terminate  before  the  elimi- 
nation of  the  sloughs  commences,  the  separation  of 
these  may  open  large'  vessels,  from  which  the 
hemorrhage  will  rapidly  destroy  life.     The  great 


APPEARANCES    OF    HOSPITAL    GANGRENE.  215 

nerves  and  arteries  appear  to  resist  the  gangrenous 
destruction  longer  than  the  muscular  or  cutaneous 
structures.  These  yield  in  the  end,  and  repeated 
hemorrhages  close  the  scene. 

I  -witnessed  an  epidemic  of  hospital  gangrene, 
in  Milan,  during  the  summer  of  1859.  A  large 
number  of  Austrian  wounded  had  been  put  in 
a  barrack  prepared  for  their  reception.  They 
had  undergone  many  hardships,  retreating  daily 
before  a  victorious  enemy,  and  had,  prior  to 
the  battle  of  Solferino,  tasted  no  food  for 
forty-eight  hours.  They  had  been  deceived  by 
their  leaders,  who  had  taught  them  that  certain 
death  awaited  them  should  they  fall  into  the  hands 
of  the  Italians.  With  these  impressions,  the 
wounded  hid  themselves  in  the  ditches  and  under- 
brush of  the  extended  battle  field,  where  many 
perished.  Some  were  not  discovered  for  two  or 
three  days,  when  they  were  sent  to  the  hospitals. 
The  previous  hardships  which  the  Austrians  had 
undergone,  their  lymphatic  tendencies,  their  irre- 
gular living,  with  the  moral  depression  of  repeated 
defeat,  exposed  them  to  the  ravages  of  the  lowest 
forms  of  disease.  Hospital  gangrene  raged  fear- 
fully among  them,  destroying  numbers.  Many  of 
their  wounds  were  frightful  from  the  extended 
sloughing,  and  their  worn  frames  and  gaunt  vis- 


216  APPEARANCES    OF    HOSPITAL    GANGRENE. 

ages  indicated  a  fearful  combat  with  disease.  I 
was  particularly  struck  with  the  mental  depression 
under  which  many  of  them  were  Buffering — 
amounting  to  despondency.  This  was  further  in- 
creased by  the  attendants  and  surgeons  not  speak- 
ing the  German  language,  so  that  neither  could 
their  wants  be  known  nor  could  sympathy  be 
extended  to  them.  From  this  combination  of 
depressing  causes,  an  epidemic  of  sloughing  pha- 
gadcena  appeared,  which  was  appalling  even  to 
those  accustomed  to  see  disease  in  its  most  fearful 
form. 

McLeod  tells  us  that,  in  the  Crimea,  during  the 
heat  of  the  summer  of  1855,  not  a  few  of  those 
operated  upon  were  lost  by  a  gangrene  of  a  most 
rapid  and  fatal  form.  All  of  those  attacked  by  it 
were  carried  oft.  In  the  case  of  a  few,  who  lived 
long  enough  for  the  full  development  of  the  dis- 
ease, gangrene  in  its  most  marked  features  became 
established ;  but  most  of  them  expired  previous 
to  an}'  sphacelus  of  the  part,  overwhelmed  by  the 
violent  poison  which  seemed  to  pervade  and 
destroy  the  whole  economy.  "  The  cases  of  all 
those  who  died  in  my  wards  seemed  to  be  doing 
perfectly  well  up  to  sixteen  hours,  at  the  furthest, 
before  death.  During  the  night  previous  to  death, 
the  patient  was  restless,  but  did  not  complain  of 


LOCAL    TREATMENT.  217 

any  particular  uneasiness.  At  the  morning  visit, 
the  expression  seemed  unaccountably  anxious,  and 
the  pulse  very  slightly  raised,  the  skin  moist,  and 
the  tongue  clean.  By  this  time  the  stump  felt,  as 
the  patient  expressed  it,  heavy,  like  lead,  and  a 
burning,  stinging  pain  had  begun  to  shoot  through 
it.  On  removing  the  dressing,  the  stump  was 
found  slightly  swollen  and  hard,  and  the  discharges 
thin  and  gleety,  colored  with  blood,  and  having 
masses  of  matter,  like  gruel,  occasionally  mixed 
with  it.  A  few  hours  afterward,  the  limb  would 
be  greatly  swollen,  the  skin  tense  and  white,  and 
marked  along  its  surface  by  prominent  blue  veins. 
The  cut  edges  of  the  stump  looked  like  pork. 
Acute  pain  was  felt.  The  constitution  by  this  time 
had  begun  to  sympathize.  A  cold  sweat  covered 
the  body,  the  stomach  was  irritable  and  the  pulse 
weak  and  frequent.  The  respiration  became  short 
and  hurried,  giving  evidence  of  the  great  oppres- 
sion of  which  the  patient  so  much  complained. 
The  heart's  action  gradually  and  surely  got  weaker 
till,  from  fourteen  to  sixteen  hours  from  the  first 
bad  symptom,  death  relieved  his  sufferings." 

In  the  treatment  of  hospital  gangrene,  we  must  con- 
sider  it    frequently    a   local    disease,    with    rapid 
tendency  to  constitutional  poisoning.     One  of  our 
early  duties  would  be  to  destro}^  the  accumulating 
19 


218  LOCAL    TREATMENT. 

poisonous  ichor  in  the  wound  to  prevent  further 
infection,  whilst,  at  the  same  time,  we  correct  those 
depressing  causes  which  predisposed  to  the  disease. 
Guthrie  says,  that  constitutional  treatment,  and 
every  kind  of  simple,  mild,  detergent  applications, 
always  failed  unless  accompanied  by  absolute 
separation,  the  utmost  possible  extent  of  ventila- 
tion and  the  greatest  possible  attention  to  clean- 
liness; and  not  even  then  without  great  loss  of 
parts  in  many  instances. 

The  local  remedies  act  as  caustics,  and  compose 
the  most  energetic  of  the  pharmacopoeia.  The 
French  and  German  military  surgeons  prefer  the 
actual  cautery  to  all  other  applications  to  check 
the  encroachments  of  the  disease,  although  Ar- 
mand  even  speaks  of  this  remedy,  upon  which 
much  reliance  was  placed,  as  exceptionally  check- 
ing the  progress  of  mortification.  "  After  a 
thorough  cauterization,  the  eschar  separates  rap- 
idly, and  often  exposes  a  second  infected  surface 
of  greater  extent."  His  individual  experience 
gives  the  preference  to  tincture  of  iodine  as 
a  local  application.  The  best  results  were 
obtained  when  a  compress  saturated  with  it  was 
applied  to  the  wound.  Guthrie  recommends 
the  liberal  use  of  the  concentrated  mineral  acids, 
especially  the  fuming  nitric  acid.  McLeod  refers 
to  the  nitric  acid  as  the  most  efficacious  means  of 


LOCAL    TREATMENT.  219 

stopping  the  sloughing  process.  Laborraque's 
chloride  of  soda,  pyroligneous  acid,  creasote,  per 
chloride  of  iron,  lemon  juice,  etc.,  are  frequently 
used  with  benefit ;  but  general  experience  in  mili- 
tary surgery  gives  the  preference  to  the  mineral 
acid  preparations.  These  are  to  be  followed  by 
irrigation,  which  washes  away  the  ichorous  dis- 
charges as  rapidly  as  they  form,  and  prevents 
further  infection.  Powdered  charcoal,  camphor 
and  bark  poultices  are  useful  applications. 

The  local  treatment  alone,  without  the  constitu- 
tional, would  be  followed  by  no  good  results.  The 
most  important  of  all  the  constitutional  remedies  is 
change  of  air.  If  the  patient  could  be  removed  from 
the  atmospheric  influences  of  the  infected  ward, 
his.  chances  for  recovery  would  be  greatly  in- 
creased. Baudens  states  that  without  isolation  all 
treatment  will  show  itself  powerless.  Carrying  the 
patient  from  the  ward  to  a  tent  would  be  followed 
by  immediate  amelioration — fresh  air  being  the 
great  remedy.  Keeping  the  intestinal  action  free 
by  a  little  blue  mass,  or  compound  extract  of  colo- 
cynth,  and  the  liberal  use  of  tonics  and  stimulat- 
ing diet,  with  wine  or  brandy  and  opium,  will  com- 
plete the  treatment.  Opium  is  required  in  every 
stage  of  the  disease,  and  is  administered  in  large 
and  repeated  doses  to  allay  the  pain,  irritability  and 


220  SIMILARITY    OF    LOW    DISEASES. 

sleeplessness,  which  so  generally  attend  the  severe 
cases  of  gangrene.  The  diet  throughout  should 
be  highly  nutritious  and  should  be  liberally  pre- 
scribed. McLeod,  in  his  experience  in  the  English 
service,  states  "  that  nitric  acid,  applied  locally, 
and  the  exhibition  of  the  tincture  of  the  muriate 
of  iron  internally  in  half  drachm  doses,  three  times 
a  day,  proved  to  be  the  most  efficacious  means  of 
stopping  it,  as  it  appeared  in  our  hospitals." 

It  is  thus  seen  that  the  three  most  fatal  compli- 
cations to  gunshot  wounds  are  the  three  kindred 
diseases,  erysipelas,  pyaemia,  and  hospital  gan- 
grene, all  recognizing  a  common  origin  —  viz., 
imperfect  ventilation  and'  want  of  proper  atten- 
tion to  cleanliness,  with  the  absence  of  those 
hygienic  regulations  necessary  for  the  health  of 
an  army. 

With  proper  care  from  the  medical  corps,  these 
diseases,  which  are  the  chief  scourges  to  the 
wounded,  and  the  causes  of  nearly  all  the  deaths, 
can  be  in  a  measure,  if  not  altogether,  prevented. 
Once  they  have  made  their  appearance  in  a  hos- 
pital, they  will  never  leave  until  the  building  is 
closed,  and  the  proper  measures  for  purification 
resorted  to.  Prevention,  in  this  instance  as  in  all 
others,  will  be  found  better  than  attempts  at  cure, 
as  many  of  these  diseases,  once  they  appear,  are 


TETANUS.  221 

quite  unmanageable,  and  tend  naturally  to  a  fatal 
issue.  All  of  these  diseases  are  benefited  by  the 
isolation  of  the  patient  iu  a  pure  atmosphere, 
when  the  infectious  character  of  the  disease  is 
counteracted,  and  the  patient  is  in  the  best  condi- 
tion for  successful  treatment.  In  all  of  them  the 
antiphlogistic  treatment  cannot  be  too  severely 
condemned.  However  useful  such  a  course  may 
be  in  a  civil  hospital,  or  in  private  practice,  with 
patients  unexposed  to  hardships,  who  are  robust 
and  have  not  been  influenced  by  depressing 
agents,  in  a  military  hospital  with  the  material 
which  compose  the  inmates,  an  antiphlogistic 
course  should  not  be  thought  of.  The  supporting 
plan,  with  stimulating  tonics,  is  the  onry  rational 
course  that  promises  success,  and  should  be  used 
throughout  the  treatment.  Attending  to  the  se- 
cretions with  mild  remedies,  allaying  pain,  and 
inducing  refreshing  sleep  by  means  of  opium, 
good  diet,  and  due  regard  to  hygienic  regulations, 
will  be  the  course  of  practice  to  be  pursued. 

Tetanus.  —  Another  fatal  complication  of 
wounds,  depending,  however,  upon  very  different 
circumstances  from  those  recently  considered,  is 
tetanus  or  lockjaw:  a  disease  fearfully  malignant 
under   any  circumstances,   and   with   scarcely   an 


222  TETANUS. 

exception  in  military  surge ry.  Fortunately,  this 
is  never  an  epidemic,  nor  can  it  infect  a  hos- 
pital, although  pathologists  have  recently  at- 
tempted to  prove  its  origin  traceable  to  an  animal 
poison.  This  disease  is  much  more  frequent  with 
us  than  it  is  in  Europe,  where  it  is  rarely  met 
with.  In  the  Crimean  service,  McLeocl  men- 
tions but  thirteen  cases  as  occurring  in  camp  and 
in  the  hospitals. 

This  disease,  which  does  not  depend  upon  the 
size  of  the  wound  from  which  the  patient  is  suf- 
fering, appears  to  be  caused  frequently  by  sudden 
atmospheric  changes  connected  with  dampness. 
Larrey,  in  his  experience  both  in  Germany  and 
Egypt,  found  it  in  those  wounded,  who,  after 
sustaining  great  exertions  during  the  fight  on  a 
very  hot  day,  were  exposed  to  the  cold,  damp 
night  air  on  the  field,  without  shelter.  After  the 
battle  of  Bautzen,  where  the  wounded  were  left 
on  the  field  during  the  night,  exposed  to  severe 
cold,  Larrey  found  on  the  following  morning  that 
more  than  one  hundred  were  affected  by  tetanus. 
In  very  hot  climates  it  requires  but  little  excite- 
ment to  produce  it — a  trifling  puncture  or  scratch 
is  at  times  sufficient  to  cause  an  attack,  and  it 
has  been  noticed  by  military  surgeons  that  the 
scraping  of  the  skin  by  a  ball,  with  bruising  of  the 


SYMPTOMS    OF    TETANUS.  223 

nerves,  is  more  liable   to  this  complication  than 
the  more  severe  wounds. 

The  proximate  cause  appears  to  be  some  in- 
jury to  the  nerves  of  the  body,  not  necessarily 
connected  with  an  open  wound,  as  it  has  been 
known  to  follow  the  blow  of  a  whip  or  a  sprain. 
Wounds,  in  certain  situations  are  thought  to 
favor  its  appearance,  viz.,  injury  to  the  hands, 
feet,  joints,  etc.  It  may  occur  very  speedily — a 
few  hours  after  the  injury  has  been  received,  or 
it  may  not  occur  for  days.  Rarely  does  it  attack 
chronic  wounds  after  the  twentieth  day.  Its 
common  period  for  appearing  is  between  the  fifth 
and  fifteenth  day,  when,  perhaps,  the  simple 
wound  has  completely  cicatrized.  The  premo- 
nition of  uneasiness  on  the  part  of  the  patient, 
with  vague  fears  of  impending  trouble,  disturbed 
digestion,  etc.,  are  not  often  observed. 

The  first  symptom  which  we  usually  recognize 
is  a  complaint  of  soreness  of  the  throat,  which, 
in  ordinary  cases  precedes,  by  some  hours,  the 
contraction  of  the  muscles  of  the  jaw  and  pinch- 
ing of  the  features.  The  spasm,  instead  of  com- 
mencing in  the  injured  part,  always  shows  itself 
first  in  those  muscles  supplied  by  the  fifth  pair  of 
nerves,  and  although  in  sudden  and  violent  cases 
the    spasmodic    contraction   of  the   muscles   gen- 


224  TREATMENT  OP  TETANUS. 

erally  may  rapidly  follow  the  locking  of  the  jaws, 
or  appear  to  be  even  simultaneous  with  it,  they 
are  never  found  to  precede  it.  The  locking  of 
the  jaws ;  the  contraction  of  the  muscles  of  the 
neck,  especially  the  sterno-cleido-mastoid,  which, 
by  bounding  under  the- skin,  accurately  defines  the 
triangles  of  the  neck;  the  hardened  condition  of 
the  abdominal  muscles,  tjie  knots  formed  over 
the  region  of  the  recti  muscles  during  the  par- 
oxysm; the  stiffening  of  the  muscles  of  the  legs, 
whilst  those  of  the  arms  remain  free ;  the  sar- 
donic expression  of  the  face ;  clear  brain ;  sleep- 
lessness; profuse  SAveating;  incessant  desire  to 
drink,  and  difficulty  in  accomplishing  it;  with 
the  occurrence  of  paroxysms  of  violent  muscular 
contraction  every  few  minutes,  with  loss  of 
strength  in  the  pulse,  and  rapid  prostration,  de- 
fine the  disease  so  accurately  that  it  becomes  one 
of  those  most  easily  recognized. 

Any  one  who  has  ever  felt  a  cramp  of  the  calf 
muscles,  may  have  a  faint  appreciation  of  the 
intense  pain  which  a  permanent  and  violent 
cramp  of  all  the  muscles  must  produce — a  pain 
sufficient  to  destroy  life  promptly,  through  ner- 
vous exhaustion. 

The  prognosis  of  this  disease  is  so  serious,  and 
the  treatment,  however  conducted,  so  unsatisfac- 


TREATMENT  OF  TETANUS.  225 

tory,  that  many  surgeons  of  large  experience  have 
never  cured  a  case  of  traumatic  tetanus.  That 
fruitful  source  of  information,  pathology,  gives  us 
no  instruction  in  this  disease.  An  autopsy  re- 
veals nothing  commensurate  with  the  intensity  of 
symptoms.  A  slight  congestion  of  the  spinal 
cord  and  medulla  oblongata,  is  all  that  can  be 
discerned.  From  the  symptoms,  we  judge  of  the 
disease  as  one  of  intense  nervous  irritation.  Rec- 
ognizing the  exhaustion  which  so  soon  shows 
itself,  the  treatment  as  laid  down  by  the  most 
recent  authors,  and  the  one  now  generally  adopt- 
ed, is  one  of  support  to  both  the  nervous  and 
muscular  systems. 

Larrey  has  cut  short  the  disease  in  its  incipient 
stage  by  amputating  the  limb,  or  dividing  the 
nerve  which  is  supposed  to  be  at  fault.  Other 
surgeons,  by  isolating  the  irritation,  have  been 
equally  successful.  Such  results  are,  however, 
rarities  in  practice,  the  operation  often  failing 
when  performed  at  the  very  commencement  of 
the  symptoms,  and  always  when  the  disease 
shows  confirmed  general  spasms.  At  times, 
patients  suffering  from  tetanus  get  well  under 
the  most  varied  treatment.  Nearly  every  power- 
ful remedy  in  the  pharmacopicea  has  been  rec- 
ommended  as    a    sovereign  cure   by   those   who 


226  TREATMENT  OF  TETANUS. 

may  have  derived  some  benefit  from  such  in  the 
treatment  of  tetanus.  Disappointment  is  sure  to 
follow  the  confidence  placed  in  any  of  these  arti- 
cles. The  most  judicious  course  is  to  disclaim  all 
specific  remedies,  and  be  guided  by  the  symp- 
toms; allay,  if  possible,  the  intense  nervous  ex- 
citement, and  support  the  system  against  the 
ensuing  exhaustion. 

The  local  treatment  should  consist  in  examin- 
ing the  wound  for  foreign  bodies,  and  removing 
them,  if  possible,  as  they  are  frequently  the  ex- 
citing cause  of  nervous  irritation,  under  the  pre- 
sumption that  unless  the  local  cause  be  removed 
we  can  expect  but  little  abatement  of  the  general 
tetanic  excitement.  Should  no  foreign  body  be 
found,  if  it  be  possible,  an  incision  may  be  made 
on  the  cardiac  side  of  the  wound,  to  divide  the 
nerves  implicated,  and  paralyze  their  sensibility. 
The  powerful  acids  and  the  actual  cautery  have 
been  recommended  for  the  similar  purpose  of 
destroying  the  excited  nerves  at  the  seat  of 
injury.  A  solution  of  morphine,  atropine  or 
kindred  preparations,  may  be  instilled  into  the 
wound  for  their  sedative  action,  and  the  simple 
water  dressing  continued. 

The  constitutional  treatment  will  have  for  its 
object  to  remove  all  general  and  internal  causes 


TREATMENT    OF    TETANUS.  -i-  / 


which  may  keep  up  excitement.  We  should  con- 
stantly bear  in  mind  that  tetanus  is  an  affection  of 
debility,  and  that  the  violence  of  the  spasmodic 
paroxysm  gives  a  false  appearance  of  strength 
to  the  patient, '  whilst  the  principal  source  of 
danger  and  death  is  from  fatigue,  induced  by 
the  energy  of  the  muscular  movements  and  the 
consequent  want  of  rest. 

As  the  bowels  are  always  constipated  and 
loaded  with  offensive  fcecal  collections,  which 
might  assist  in  sustaining  the  excitement  of  the 
nervous  system,  they  should  be  at  once  emptied 
by  a  large  dose  of  calomel,  with  gamboge,  aloes, 
or  scammony.  When  a  difficulty  is  found  in 
administering  this,  from  the  locked  condition  of 
the  jaw,  one  or  two  drops  of  croton  oil  can  be 
placed  within  the  teeth,  when,  mingling  with  the 
saliva,  it  will  be  swallowed.  Three  or  four  times 
the  ordinary  dose  will  be  required  to  relieve  the 
torpid  bowels.  The  patient  should  then  be  kept 
perfectly  quiet — if  possible  by  himself,  as  the  stir- 
ring about  of  persons,  noises,  draughts,  etc., 
excite  sudden  and  repeated  paroxysms  of  spasm. 
Ice  bladders,  blisters,  or  chloroform  applications, 
may  be  made  to  the  upper  portion  of  the  spine 
to  allay,  if  possible,  the  irritation  of  this  region. 

Although  opium  is  universally  administered  as 


228  TREATMENT  OE  TETANUS. 

an  internal  sedative,  its  effects  are  not  often 
obtained  even  when  given  in  large  doses.  It  is 
believed  that  it  often  remains  unabsorbed  in  the 
stomach,  and,  therefore,  without  action.  The 
same  for  conium  hyoscyamus  and  the  entire  class 
of  sedatives  when  given  in  the  form  of  pill  or 
extract.  Unless  medicines  are  given  dissolved, 
they  are  not  likely  to  be  absorbed,  or  they  are 
taken  up  so  slowly  that  their  good  effects  are  not 
perceived. 

Recently,  in  two  cases  of  traumatic  tetanus,  I 
have  tried  the  hypodermic  administration  of  mor- 
phine in  ^  grain  doses,  dissolved  in  a  few  drops  of 
water,  and  injected  by  means  of  a  Wood's  syringe. 
The  effect  of  the  remedy  in  a  few  minutes  was 
decided,  but  was  not  persistent ;  partial  relaxation 
of  the  jaws  could  always  be  effected,  so  that  nour- 
ishment might  be  taken,  and  sleep  could,  also,  be 
induced.  It  is  by  far  the  preferable  mode  of 
using  opium,  as  its  effects  can  be  speedily  and 
with  certainty  obtained.  In  one  case,  in  which  I 
injected  1-1  Oth  grain  of  atropine  under  the  skin  of 
the  arm,  the  effect  upon  the  pulse  was  so  imme- 
diate that,  in  five  minutes,  it  had  increased  from 
eighty  to  one  hundred  and  fifty  beats.  It  rapidly 
affected  the  salivary  and  mucous  glands  of  the 
mouth  —  diminishing    their    secretions    without, 


TREATMENT  OF  TETANUS.  229 

however,  producing  dilatation  of  the  pupils  or 
causing  relaxation  of  the  muscles.  As  no  bene- 
ficial effect  followed  the  atropine  injection,  mor- 
phine had  to  be  used,  when  relaxation  to  a  cer- 
tain extent  was  immediately  obtained. 

The  liberal  use  of  belladonna  has  been  recom- 
mended, and,  from  its  great  utility  in  relieving 
congestions  of  the  lower  portion  of  the  spinal 
cord,  we  might  naturally  infer  similar  good  effects 
for  the  medulla  oblongata.  The  tincture  of 
canabis  indica  has  been  highly  extolled.  Some 
cases  have  recovered  under  its  use,  but  a  very 
much  larger  number  have  died  in  spite  of  its  ad- 
ministration. Stimulating  and  nourishing  fluids 
must  be  liberally  administered  at  regular  inter- 
vals, and,  notwithstanding  the  difficulty  in  swal- 
lowing, the  nurse  should  insist  upon  its  being  taken. 
Many  a  fatal  case  can  be  laid  to  the  charge  of 
carelessness  in  nursing,  where  the  wishes  of  the 
patient  are  permitted  to  regulate  the  nurse's 
duties.  Beef  tea,  eggs,  milk,  custards,  egg-nog 
and  wine  must  be  frequently  poured  down  the 
throat  of  the  unwilling  patient,  and,  if  the  mouth 
cannot  be  sufficiently  opened,  the  inhalation  of 
chloroform,  or  the  endermic  use  of  morphine 
should  be  used  to  effect  it.  I  have  seen  excel- 
lent results  with  either  of  these  relaxing  agents. 


230  TREATMENT  OP  TETANUS. 

I  have  found  porter  an  excellent  tonic  in  such 
cases,  as  it  combines  both  sedative,  nourishing 
and  stimulating  or  supporting  properties.  Under 
the  frequent  inhalation  of  chloroform,  the  spasms 
can  often  be  kept  under  control. 

By  pursuing  the  above  course  of  keeping  the 
patient  quiet,  using  sedatives  with  forced  nourish- 
ment, and  relieving  the  loaded  intestines  by  cro- 
ton  oil,  I  have  had  the  good  fortune  of  saving 
three  tetanic  patients  out  of  six  cases  which 
have  come  under  my  personal  observation.  As 
the  three  first  cases  which  I  treated  were  all 
restored  to  health,  although  they  were  very 
severe,  I  imagined  that  I  had  found  a  successful 
mode  of  treating  tetanus,  and  published  the 
same  in  the  Charleston  Medical  Journal  for  1857. 
Since  that  time,  I  have  had  three  cases  under  ob- 
servation and  lost  them  all,  notwithstanding  the 
same  course  was  pui'sued  as  in  the  successful 
cases. 

When  the  patient  is  able,  constant  smoking  of 
strong  segars  may  be  useful  in  quieting  the 
excited  nervous  system.  The  impression  among 
many  observing  surgeons  is,  that  the  patient  is 
destroyed  by  exhaustion,  called  by  some  starva- 
tion. It  is  known,  that  if  the  patient  can  be 
kept   alive   to   the   sixth    day    after    the    attack, 


TREATMENT    OF    TETANUS.  231. 

there  is  a  likelihood  of  his  recovery,  and  that 
by  the  tenth  day  he  may  even  he  considered 
convalescent.  If  the  debilitating  effects  of  the 
disease  can  be  counteracted  by  the  free  admin- 
istration of  very  nutritious  food,  such  as  brandy 
and  eggs,  etc.,  many  surgeons  believe  that  the 
nervous  irritation  will  wear  itself  out.  It  is  based 
upon  this  belief,  and  the  known  failures  of  the 
spoliative  plan  of  treatment,  that  the  above  plan 
is  now  recommended. 

Woorara  poison  has  been  recommended  as  an 
antidote  from  its  known  powerful  sedative  ner- 
vous action  and  its  marked  influence  in  counter- 
acting the  effects  of  strychnia.  When  poisonous 
doses  of  these  substances  are  given  conjointly,  no 
poisonous  effects  are  observed.  The  striking 
similarity  between  the  spasms  produced  by  strych- 
nine and  those  of  lockjaw,  suggested  the  use  of 
woorara  in  this  latter  disease.  As  experiments 
proved  it  efficacious  in  the  tetanus  of  animals,  its 
field  of  usefulness  was  enlarged  to  the  human 
subject.  Several  cases  of  its  successful  use  in 
chronic  tetanus  are  reported.  There  is  much 
difficulty  in  obtaining  good  specimens  of  this 
remedy.  As  no  two  possess  similar  properties, 
each  must  be  tested  by  experiment  before  it 
can   be    tried    upon  the    human    subject.     Cases 


232  HECTIC    FEVER. 

are  reported  where  its  use  hastened  the  death  of 
the  patient,  It  was  first  used  by  inoculation, 
now  it  is  administered  in  the  form  of  a  mixture : 
ten  grains  of  tjie  woorara  to  a  six  ounce  mix- 
ture— a  tablespoonful  every  half  hour  until  perfect 
relaxation  is  produced.  Should  poisonous  effects, 
with  death-like  symptoms,  show  themselves  from 
an  over-dose,  artificial  respiration  will  support  life 
and  sustain  the  action  of  the  heart  until  the  poi- 
son is  eliminated  from  the  circulation  b}^  the 
kidneys.  The  rationale  of  the  remedy  is  to  keep 
the  spasms  from  killing  the  patient  by  their 
violence,  until  the  morbid  state  calling  them  into 
play  has  exhausted  itself. 


The  not  unfrequent  sequela  of  severe  gunshot  wounds 
is  long-continued  discharge,  producing  emaciation  and 
hectic,  with  its  gradual  dissolution  of  body  and  soul. 
It  is  not  at  all  surprising  that  the  daily  dis- 
charge of  a  wound,  when  at  all  profuse,  should 
cause  debility,  as  we  have  already  characterized 
pus  as  the  nutritive  essence  of  the  circulating 
fluid.  If  the  surgeon,  who  has  many  suppurating 
wounds  under  his  care,  overlooks  the  fact  that  he 
must  make  allowance  for  this  drain  and  feed  the 


HECTIC    FEVER.  233 

wound  as  well  as  the  patient,  the  wound  heing 
more  imperious  in  its  demands  than  the  economy, 
deprives  the  latter  of  its  due  supply  of  nourish- 
ment, and  progressive  starvation  must  follow.  It 
is  on  this  account  that  what  is  called  the  antiphlo- 
gistic treatment,  when  fully  carried  out  in  the 
treatment  of  suppurating  wounds,  is  injurious, 
and  that  the  supporting  plan  is  required.  With 
diet,  we  have  a  powerful  weapon  for  weal  or 
woe  in  surgical  practice.  Soon  after  injuries 
have  heen  received,  when  reaction  runs  high,  by 
abstemiousness  we  can  do  much  to  quiet  exces- 
sive irritability.  But  as  soon  as  this  stage  has 
passed,  and  suppuration  has  become  established, 
then  the  course  of  diet  should  be  modified ;  now, 
liberal  diet  is  necessary  to  prevent  the  febrile 
complication,  which,  in  the  early  stage  of  the 
wound,  abstemiousness  controlled. 

The  use  of  an  abundance  of  strong  nutritious 
food,  by  enriching  the  blood,  will  increase  the 
vital  properties  of  the  plasma,  improve  the  tone 
of  the  tissues,  stop  the  excessive  demands  of  the 
irritated  wounded  parts,  and  diminish  the  drain. 
This  treatment,  with  the  liberal  use  of  the  astrin- 
gent tonics,  and  the  injection  of  stimulating 
astringents  into  the  wound  (as  nitrate  of  silver, 
ten  grains  to  one  ounce  of  water,  or  tincture  of 
20 


234  PERIODIC   PAINS. 

iodine,  or  the  acid  tinctures  of  iron  diluted,  one 
part  to  five  of  water),  will  gradually  diminish  a 
discharge,  which,  under  less  supporting  treatment, 
would  continue  for  a  much  longer  period.  The 
economy  cannot  withstand  this  constant  drain ;  it 
becomes  irritable  in  its  weakness.  In  its  efforts 
to  throw  off  the  yoke,  it  still  further  enfeebles 
itself.  Daily  fevers,  with  their  profuse  sweats, 
reappear  with  fearful  regularity.  Finally,  the 
blood  becomes  so  poor,  that  it  deteriorates  rap- 
idly, and  the  useless  material  which  is  ejected 
from  the  circulation,  irritating  the  organs  through 
which  it  passes,  causes  diarrhoea,  and  also  copious 
deposits  in  the  urine.  The  quadruple  drain  from 
wound,  skin,  bowels  and  kidneys,  cannot  long 
be  resisted.  Debility  gradually  increases,  the  pa- 
tient rapidly  wastes  to  a  living  skeleton,  having 
literally  melted  away,  and  at  last  dies  from  sheer 
exhaustion — the  conjoined  result  of  mal-nutrition 
and  wasting  discharges.     Such  is  hectic  fever. 


Another  sequela  of  gunshot  wounds  is  more  or 
less  permanent  or  periodic  pain  in  the  injured  limb, 
connected  or  not  with  paralysis  of  certain  mus- 
cles, the  nervous  supply  to  which  has  been  impair- 
ed by  the  ball  in  its  passage.     When  a  nerve  has 


PERIODIC    PAINS.  235 

been  completely  divided,  permanent  paralysis, 
with  atrophy  of  the  muscles,  ensues — the  limb 
gradually  dwindling,  if  the  muscles,  indirectly  de- 
stroyed, be  important  to  the  common  movements 
of  the  extremity.  A  bruising  of  the  nerves, 
without  division,  is  also  followed  by  a  paralysis 
more  or  less  persistent,  which  time,  however,  and 
stimulating  embrocations  will,  to  a  great  extent, 
remedy.  This  is  not  so  much  the  case  in  sabre 
wounds.  Where  a  nerve  is  divided  by  a  sharp, 
cutting  instrument,  when  the  tissues  are  not  dis- 
placed and  the  wound  heals  without  suppuration, 
both  experiments  upon  animals  and  experience  in 
man  show  that  a  reunion  of  the  ends  of  the 
nerves  is  effected,  and  nervous  action  restored  to 
its  former  integrity. 

"When  nerves  are  pricked,  or  iu  any  other  way 
injured  without  complete  division,  very  severe 
neuralgic  pains,  with  spasmodic  action  of  the  mus- 
cles of  the  limb,  ensue.  These  pains  extend  up 
and  down  the  injured  limb,  and,  as  in  cases 
reported  by  Guthrie,  have,  with  irregular  inter- 
missions, annoyed  the  patient  for  years.  In  one 
case,  although  the  severity  of  the  symptoms  sub- 
sided after  six  or  seven  years,  annoyance  was, 
at  times,  experienced  forty  years  after  the  injury 
had  been  received.     A  coldness  of  the  parts  sup- 


2o(3  PERIODIC    PAINS. 

plied  by  the  injured  nerve  is  not  an  uncommon 
effect,  and  is  more  or  less  persistent.  Sudden 
changes  in  the  temperature,  cold  weather,  or 
mental  excitement,  are  among  the  exciting  causes 
of  such  attacks  The  best  means  of  mitigating  the 
suffering,  independently  of  the  application  of  warm 
flannels,  is  the  free  use  of  stimulating  narcotic 
embrocations.  Any  combination  from  the  man}T 
articles  of  the  materia  medica,  of  stimulating  and 
narcotic,  or  anaesthetic  ingredients,  would  fulfil 
the  indications  of  treatment.  The  internal  use 
of  quinine,  aconite,  hyoscyamus,  belladonna  or 
opium,  will  blunt  sensibility. 

The  en  dermic  use  of  morphine  in  one-fourth 
grain  doses,  or  aconitine,  one-sixteenth  of  a 
grain  dissolved  in  two  or  three  drops  of  water, 
will  give  immediate  relief — in  some  instances 
a  permanent  cure  has  followed  the  first  injec- 
tion. Great  reliance  will  hereafter  be  placed 
upon  this  new  method  of  treatment.  A  complete 
division  of  the  nerve  at  fault  has  been  recom- 
mended, and  practiced  with  some  good  results; 
but  the  divided  nerve  is  liable  to  become  diseased, 
or  its  cut  ends  swell  into  a  neuroma,  which,  incor- 
porating itself  with  the  cicatricial  tissue,  would, 
from  the  amount  of  pressure  exercised  by  the  new 
formations,  allow  of  only  temporary  relief. 


CHAPTER    VII, 

Treatment  of  wounds  of  the  different  parts  of  the  body, 
or  topical  surgery — Wounds  of  the  head;  Concus- 
sion; its  characters  and  treatment — Compression; 
its  symptoms — Variety  of  wounds  of  the  head; 
their  prognostic  value — Simple  wound  of  the  scalp; 
treatments — Fracture  without  depression;  course  to 
be  pursued  when  inflammation  of  the  brain  threat- 
ens— Fracture,  with  depression,  to  be  treated  with- 
out an  operation  —  Trephining  very  rarely  called 
for — Compound  fracture,  with  depression  and  com- 
pression; trephining  even  here  of  doubtful  propri- 
ety— Perforating  ivounds  of  the  cranium  complicated 
with  foreign  bodies. 

"Wounds  of  the  head,  when  received  in  battle, 
require  a  special  treatment,  which  cannot  be  en- 
grossed in  the  routine  practice  for  wounds.  Qwi#g 
to  the  proximity  of  the  brain  and  membranes, 
and  the  facility  with  which  shocks  or  direct  injury 
can  be  transmitted  through  the  protective  envel- 
opes, injuries  of  the  head  possess  a  peculiar  sig- 
nificance.    All  wounds  of  the  head  are  more  or 


238  CONCUSSION. 

less  serious,  as  the  surgeon  can  never  know  in 
advance  whether  the  brain  be  injured,  and  what 
amount  of  irritation  or  inflammation  will  ensue 
upon  such  an  occurrence.  Hence  the  necessity 
of  caution  in  prognosis  and  treatment,  which  the 
experienced  surgeon  will  always  exhibit,  however 
trivial  the  wound  may  appear. 

Injuries  of  the  head  would  divide  themselves 
into  those  produced  from  shot,  those  from  the 
bayonet  or  clubbed  musket,  and  those  caused  by 
the  blow  of  a  sabre.  Wounds  are  found  of  every 
grade  of  intensity,  from  a  simple  scratch  to  ex- 
tensive destruction  of  the  soft  and  hard  parts, 
with  or  without  those  phenomena  recognized  as 
concussion  and  compression.  As  these  terms 
will  be  continually  referred  to  in  speaking  ot 
the  treatment  of  head  injuries,  we  will,  in  brief' 
define  the  meaning  which  the  surgeon  attaches 
to  them. 

Concussion,  or  stunning,  appears  to  be  a  shock 
toethe  brain  by  which  its  substance  is  more  or  less 
shaken,  with  interference  of  its  circulation,  and 
often  injury  to  its  structure — its  functions  being 
suspended  for  a  certain  period.  Immediately  as 
an  injury  upon  the  head  has  been  received,  if  at 
all  severe,  the  patient  is  knocked  senseless.     He 


CONCUSSION. 


231) 


lies  perfectly  insensible,  motionless,  and  all  but 
pulseless.  His  face  and  surface  becomes  pale  and 
cool;  the  breathing,  although  feeble,  is  regular 
and  easily  perceived ;  the  pupils  irregularly  con- 
tracted or  dilated ;  sphincters  are  relaxed,  in 
common  with  the  entire  voluntary  muscular  sys- 
tem, so  that  the  contents  of  the  bladder  and 
bowels  often  escape  involuntarily.  After  con- 
tinuing in  this  condition  for  a  few  minutes, 
hours  or  days,  he  gradually  recovers  conscious- 
ness. The  heart  first  regains  its  accustomed 
action,  the  pulse  gradually  undergoes  develop- 
ment, and  the  skin  becomes  warmer.  At  this 
period  vomiting  usually  comes  on,  which  arouses 
the  action  of  the  heart.'  This  organ,  under  the 
excitement  of  emesis,  drives  blood  to  the  brain, 
and  with  this  free  supply  of  stimulus  to  the  gene- 
ral controlling  organ,  the  patient  rapidly  rallies. 
This  is  the  common  picture  of  concussion  as 
seen  in  surgical  practice,  and  the  combination  of 
its  symptoms  will  be  more  familiarly  recognized 
as  those  of  ordinary  tainting  or  syncope.  The 
extremes  would  be  those  cases  in  which  the  pa- 
tient staggers,  but,  after  supporting  himself  for  an 
instant  against  some  house,  fence  or  tree,  recovers 
himself  and,  without  further  annoyance,  continues 
his  employment;  or  those  in  which  the  patient  is 


240  CONCUSSION. 

picked  up  apparently  dead,  with  relaxed  muscles, 
pale  surface,  glassy  eye,  scarcely  perceptible  pulse 
and  very  feeble  and  irregular  respiration.      The 
death-like   appearance    becomes   more    and   more 
confirmed,  the  breathing  gradually  ceases,  and  the 
pulse    imperceptibly    flitters    away,   without    any 
sign  of  consciousness  from  the  moment  of  injury. 
In    fatal    cases,    where    concussion    had    been 
present,  the   brain   has   been    found   more  or  less 
injured,  and  so  highly  congested    as  to  exhibit  a 
dusky  hue.     Fissures  have  been   found  in  its  sub- 
stance, or  extravasations  of  blood  in  numerous  or 
concentrated  spots.    In  certain  instances  the  brain 
has  apparently  shrunk  from  the  excessive  shaking 
or  vibrations  to  which  it  has  been  subjected,   so 
that  it  no  longer  fills  the  cavity  of  the  skull.      In 
some  fatal  cases  where  the  brain  had  been  fissured, 
the  commotion  among  its  particles   had  at   once 
annihilated  its  functions,  so  that  the  heart's  action 
had  instantly  ceased  and  no  blood  had  been  driven 
to  the  mangled  brain  to  be  extravasated  into  its 
substance.      In     cases    of    nearly     instantaneous 
death  from  concussion  or  stunning,  the  brain,  on 
examination,   appeared  in    every  respect  healthy. 
On   the  other  hand,  in  cases  of  perfect   recovery 
after   concussion,    where    the    patient   had    lived 
some  time  (weeks  or  months)    in    the  full  enjoy- 


TREATMENT    OF   CONCUSSION.  241 

ment  of  all  of  his  faculties,  and  had  died  from 
some  disease  totally  foreign  to  the  former  head 
injury,  extensive  lesions  have  been  found  in  the 
brain,  and  traces  of  large  and  extended  extravasa- 
tions of  blood  covering  the  hemispheres  as  well 
as  in  the  cerebral  substance.  The  irritable  con- 
dition of  the  brain  in  which  the  patient^  is  often 
left,  after  concussion  of  limited  duration,  with  the 
impairment  of  memory,  or  of  some  one  of  the 
special  senses  or  even  partial  paralysis,  would  be 
physiological  proof  of  cerebral  injury.  Although 
its  symptoms  are  usually  transient,  we  may,  doubt- 
less, consider  it  a  contusion  or  interstitial  lacera- 
tion of  brain  substance. 

As  this  is  an  alarming  condition,  to  those  not 
familiar  with  the  march  of  such  lesions,  those 
interested  in  the  injured  man  are  always  clamor- 
ous for  active  interference,  and  it  is  with  difficulty 
that  the  surgeon  can  free  himself  from  the  urgent 
solicitations  of  friends  who  believe  that,  unless 
prompt  means  are  used,  the  accident  must  ter- 
minate fatally.  The  surgeon,  under  such  circum- 
stances, requires  all  of  his  presence  of  mind,  and 
with  firmness  pursues  strictly  the  non-interference 
plan  of  treatment.  The  course  which  rational 
surgery  now  recommends  is  to  lay  the  patient 
horizontally,  with  his  head  perhaps  a  little  lower 
21 


242  TREATMENT    OF    CONCUSSION. 

than  his  body,  so  that  the  brain  may  have  the 
benefit  of  gravitation  to  assist  in  its  supply  of 
blood.  He  is  wrapped  in  warm  blankets,  hot 
bottles  are  placed  around  his  body,  and  dry  fric- 
tions may  be  used  to  excite  the  re-establishment 
of  the  circulation  in  the  extremities ;  but  beyond 
this  the  surgeon  should  not  interfere.  The  safest 
■practice  consists  in  doing  as  little  as  possible.  The  use 
of  stimuli  on  the  one  hand  or  bleeding  on  the  other 
are  to  be  especially  and  studiously  avoided. 

Only  a  few  years  since  bleeding  was  the  prac- 
tice in  stunning,  and  the  amount  of  mischief  done 
by  this  universal  mania  for  bloodletting  was  often 
irreparable.  We  might  as  well  bleed  in  a  faint- 
ing fit  and  expect  good  results.  We  find,  as  in 
syncope,  that  the  heart  scarcely  pulsates  ;  so  little 
blood  is  driven  to  the  surface  that  it  is  pale  and 
cold.  The  same  for  the  brain  where  so  little 
blood  circulates  that,  from  want  of  its  proper 
stimulus,  its  functions  are  temporarily  suspended. 
Were  it  possible  to  draw  away  much  blood,  the 
cessation  of  the  nervous  functions  would  become 
permanent.  Modern  surgery,  in  studying  the 
natural  history  of  disease  and  injuries,  sees  now, 
what  it  should  long  since  have  recognized,  that 
nature,  in  her  desire  to  harbor  the  circulating 
fluid,  tries  to  put  a  safeguard  against   the   rash- 


TREATMENT    OF    CONCUSSION.  243 

ness  of  surgeons,  by  shutting  up  the  bulk  of  this 
living  fluid  in  the  inner  recesses  of  the  body, 
where  it  cannot  be  easily  despoiled.  On  account  of 
this  change  in  practice,  we  now  seldom  hear  of 
deaths  from  concussion,  which  was  comparatively 
of  common  occurrence  a  few  years  back. 

As  regards  stimulation,  we  must  also  desist  as 
long  as  it  is  possible,  and,  when  its  administration 
is  compulsory,  give  it  with  a  most  cautious,  spar- 
ing hand.  Remember  that  the  degree  and  dura- 
tion of  shock  depends  upon  the  extent  of  injury 
which  the  brain  has  received,  and  that  nature, 
always  the  most  skilful  physician,  adopts  this 
concussion  as  a  safeguard  to  prevent  further 
lesion.  How  are  we  to  know  that  the  brain  has 
not  sustained  severe  injury,  extensive  bruising  or 
laceration,  and  that  this  extreme  depression  of 
the  brain,  with  consecutive  control  of  the  heart's 
action,  is  not  especially  indicated  to  prevent  hem- 
orrhage within  the  brain  substance  and  rapid 
death  from  compression  by  extravasated  blood. 
We  know  this,  that  after  severe  injury  to  the 
brain,  when,  through  officious  meddling  and  the 
free  use  of  brandy,  the  symptoms  of  concussion 
early  disappear,  violent  reaction  is  induced,  and 
internal  hemorrhage  or  violent  inflammation  soon 
shows  itself;  and  that,  for  the  doubtful  gratifica- 


244  TREATMENT    OF   CONCUSSION. 

tion  of  seeing  the  patient  rapidly  revive,  we 
have  the  mortification  of  seeing  him  as  rapidly 
destroyed. 

Cases  of  concussion,  absolutely  requiring  Minn/louts, 
are  bat  very,  very  seldom  met  with  in  'practice.  Even 
when  of  a  very  severe  form,  all  that  is  necessary, 
in  the  vast  majority  of  cases,  is  to  apply  warmth 
to  the  surface,  and  carefully  to  watch  the  case. 

Should  it  so  happen  —  but  this  occurs  very 
rarely  —  that  the  patient  is  manifestly  in  danger  of 
sinking  from  depression  of  the  circulation,  then 
stimulants  must  be  resorted  to.  As  long  as  the 
pulse  does  not  lose  its  strength  under  concussion 
of  the  brain,  desist  from  active  interference,  should 
the  insensibility  last  for  hours  or  even  days. 
After-trouble  will  be  avoided  by  allowing  nature 
to  take  its  own  course  unmolested.  When  from 
the  great  and  long-continued  depression  stimuli 
are  called  for  to  prevent  threatening  dissolu- 
tion, their  effects  should  be  carefully  watched, 
and  as  soon  as  reaction  is  apparent,  with  an  iin- 
improving  pulse,  at  once  desist  from  further  inter- 
ference. As  is  the  state  of  depression,  so  will  be 
the  state  of  reaction.  When  the  depression  is 
extreme,  the  reaction  will  be  correspondingly 
excessive,  and,  especially  so,  if  stimuli  have  been 
freely  administered. 


COMPRESSION.  245 

When  the  patient  has  recovered  from  the  state 
of  insensibility,  he  should  be  kept  perfectly  quiet, 
excitement  of  every  kind  should  be  carefully 
avoided,  the  diet  should  be  abstemious,  the  head 
kept  cool,  and  tendency  Xo  constipation  cor- 
rected ;  but,  beyond  this,  no  treatment  is  re- 
quired until  expressly  called  for  by  excessive 
reaction,  with  symptoms  of  congestion  or  in- 
flammation of  the  brain.  The  precautionary 
bleeding,  with  repeated  doses  of  calomel,  to 
keep  off  symptoms,  which,  in  the  majority  of 
cases,  would  not  have  occurred,  was  the  routine 
practice  of  the  old  school,  and  cannot  be  too 
severely  criticised.  The  complications  which 
might  arise  in  injuries  of  the  head,  after  more 
or  less  serious  concussion,  will  be  hereafter  con- 
sidered. 


Concussion  is  always  simultaneous  with  the 
blow,  and  gradually  decreases,  if  death  does  not 
carry  off  the  patient  early.  Compression,  the  con- 
dition with  which  it  is  often  allied,  usually  comes 
on  some  little  time  after  the  reception  of  in- 
jury, although  it  may  appear  either  at  the  mo- 
ment, or  may  not  show  itself  for  days  or  even 
weeks  after  the  injury.  The  name  explains  the 
lesion.     Compression  is  pressure  made   upon  the 


246  COMPRESSION. 

brain,  either  by  a  portion  of  the  skull  or  some 
foreign  body  driven  into  or  upon  the  cerebral  mass ; 
or  by  an  escape  of  blood  from  some  torn  vessel, 
which,  by  forcing  itself  into  the  unyielding  skull, 
compresses  its  contents,  or  by  effusion  of  lymph 
or  pus,  which  inflammation  causes  to  be  deposited 
within  the  cavity  of  the  skull.  The  Bymptoms  by 
which  this  condition  would  be  recognized,  are  as 
follows: — The  patient  lies  in  a  state  of  coma, 
stupor,  or  lethargy,  being  paralyzed  more  or  less 
completely,  both  as  regards  motion  and  sensa- 
tion. He  is  heavy,  insensible,  and  drowsy,  at 
times  answers  mutteringly  when  rudely  shaken 
or  loudly  spoken,  to,  but  immediately  afterward 
is  again  breathing  slowly,  heavily  and  laboriously, 
as  if  in  deep  sleep.  Should  his  face  be  examined, 
the  lips  and  cheek  on  one  side  will  be  found  to 
flap,  during  expiration,  with  a  blowing  sound,  as  if 
smoke  was  being  blown  from  the  mouth  as  in 
smoking.  There  is  paralysis  of  that  side  of  the 
body  opposite  to  the  seat  of  injury,  and  as  a  neces- 
sary consequence,  both  in  expiration  or  in  attempts 
at  speaking,  the  corner  of  the  mouth  is  drawn 
over  to  the  sound  side.  The  countenance  is 
usually  pale,  cold,  and  ghastly,  although  it  may 
be  flushed  with  a  hot  and  perspiring  skin,  the 
eyelids  are  partly  or  completely  opened,  with  the 
pupils  dilated  and  insensible  to  light;  the  pulse 


COMPRESSION.  247 

is  slow,  the  heart  acting  under  great  oppression ; 
there  is  constipation  from  torpidity  of  the  bowels, 
with  involuntary  discharge  of  the  faeces.  From 
want  of  action  in  the  bladder  the  urine  is  re- 
tained, and  unless  drawn  off  will  decompose 
within  the  organ,  when,  from  accumulation,  either 
the  bladder  will  rupture  with  poisonous  infiltra- 
tion, or  the  blood  becomes  poisoned  from  absorp- 
tion. These  symptoms  are  not  always  equally 
marked — the  degree  depending  upon  the  cause. 
Unless  the  causes  of  compression  be  removed, 
the  case  usually  terminates  fatally,  although  cases 
are  not  rare,  in  which,  after  weeks  of  uncon- 
sciousness, reason  has  gradually  been  restored — 
the   accompanying  paralysis  slowly  disappearing. 

Having  now  explained  the  two  conditions  of 
concussion  and  compression,  which  so  commonly 
accompany  severe  wounds  of  the  head,  we  are 
better  prepared  to  study  this  special  class  of  in- 
juries. 

The  divisions  which  experience  has  proved  of 
practical  utility,  are: 

1.  Injury  to  the  soft  parts  alone,  uncomplicated  with 
injury  to  skull  or  brain. 

2.  Wound  of  soft  parts,  with  simple  fracture  of  flic 
skull. 

3.  Wound  with  depressed  fracture  of  the  skull,  but 
without  symptoms  of  compression. 


248  COMPRESSION. 

4.  Compound  depressed  fracture  of  the  skull,  with 
symptoms  of  compression  of  the  bruin. 

5.  Perforating  wounds  of  the  skull,  complicated 
with  foreign  bodies. 

From  the  peculiar  formation  of  the  skull  and 
the  resistance  which  it  offers  to  blows,  unless  a 
shot  strikes  it  fairly  at  right  angles,  it  does  not 
perforate;  but  whether  it  be  a  grape,  musket,  or 
pistol  ball,  it  flies  off  at  a  tangent,  or,  running 
beneath  the  skin  upward,  downward,  or  laterally, 
escapes.  The  head  may  even  be  struck  with  a 
round  shot  without  serious  injury.  The  patient 
may,  or  may  not  be  knocked  down  by  the  blow ; 
severe  pain  is  felt,  and  a  pufling  up  of  the  part 
instantly  follows.  When  the  hair  is  removed, 
although  there  may  be  no  discoloration  of  the 
skin,  there  is  abundant  evidence  of  subcutaneous 
lesion,  which,  unless  counteracted,  will  soon  de- 
velop inflammation  and  extensive  suppuration. 
The  severity  of  the  blow  upon  the  head  may 
have  knocked  the  patient  senseless:  and  in  this 
condition,  he  is  found  by  the  litter  carriers. 

The  transportation  of  head  injuries  requires  great 
care,  and  the  best  transports  should  be  devoted  to 
this  service.  When  the  patient  arrives  at  the  field 
infirmary,  he  is  laid  down,  with  head  low,  until  he 


COMPRESSION.  249 

recovers  himself.  The  restoration  is  left  to  na- 
ture; cold  water  may  be  dashed  into  the  face, 
but  all  stimulation  should  be  avoided  unless  the 
pulse  is  found  to  flag,  when  a  little  brandy  may 
be  cautiously  given.  The  surgeon  takes  advan- 
tage of  the  insensibility  of  the  patient,  shaves 
the  head  at  the  point  of  injury,  and  gives  the 
wound  a  thorough  examination.  When  reaction 
has  taken  place,  and  the  patient  is  restored  to 
consciousness,  should  the  wound  have  been  a 
simple  one  of  the  soft  parts,  the  cold  water 
dressings  is  all  that  will  be  required,  and  should 
be  applied  according  to  general  principles.  The 
thin,  wet  compress,  with  oiled  or  waxed  cloth 
should  cover  the  wound  and  head  for  some  dis- 
tance around  the  injury,  and  instead  of  tying 
these  in  place  by  the  roll  of  bandage,  the  better 
plan  is  to  adopt  the  head  net  of  the  Prussian 
medical  service.  It  is  a  round  piece  of  coarse 
netting  made  of  cotton  yarn :  a  string  ties  under 
the  chin  to  keep  the  dressing  on,  and  a  drawing 
string,  running  around  the  net,  like  a  purse  string, 
attaches  it  securely  to  the  head  around  the  tem- 
ples. This  is  an  admirable  dressing  for  all  head 
injuries,  which  require  light,  cool,  and  efficient 
applications. 

Should  the  soft  parts  have  been  much  bruised, 


250  TREATMENT    OF    FRACTURE    OF    SKULL. 

the  ice  bladder  will  be  required  to  keep  down 
excessive  suppuration.  To  prevent  mischief,  all 
injuries  of  the  head  demand  rest  and  quiet,  avoid- 
ance of  stimulants,  and  abstemious  diet.  By 
adopting  this  course  in  uncomplicated  wounds, 
whether  gunshot  or  sabre,  a  speedy  cure  is  usually 
obtained.  Effusions  of  blood  under  the  skin 
should  not  be  interfered  with;  incisions  are  not 
required.  If  the  effusions  are  allowed  to  remain 
excluded  from  air,  the  cold  water  dressings  with 
arnica  will  cause  their  rapid  absorption;  if  the 
skin  is  punctured  and  air  admitted,  suppuration 
will  surely  ensue.  Should  suppuration  occur,  as 
soon  as  pus  can  be  clearly  detected,  let  it  out  by 
a  small  incision.  If  this  be  neglected  at  the 
proper  time,  the  pent-up  pus  will  separate  the 
periosteum  from  the  skull,  and  cause,  perhaps,  a 
necrosis  of  the  bones.  When  suppuration  has 
been  well  established,  an  oiled  cloth  is  substi- 
tuted for  water  dressings  by  many  surgeons, 
although  the  growing  disposition  is  to  continue 
the  water  dressings  until  cicatrization  is  com- 
pleted. 

When  the  skull  has  been,  fractured  by  a  ball,  sabre 
blow,  or  fragment  of  shell,  the  treatment  should 
in  no  material  respect  differ  from  the  course  pur- 
sued in  a  simple  scalp  wound.     A  simple  or  com- 


TREATMENT    OF    FRACTURE    OF    SKULL.  251 

pound  fracture  of  the  skull,  uncomplicated  with 
injury  to  the  brain  or  its  meninges,  should  be 
managed  according  to  the  ordinary  principles  of 
surgery,  remembering  always,  however,  that  the 
brain  is  in  near  proximity,  and  may  have  been 
injured,  although  no  symptoms  are  present  for  de- 
tecting such  a  lesion.  If  the  patient  is  insensible, 
we  adopt  the  means  already  recommended  for  re- 
moving shock,  viz :  place  the  body  in  a  horizontal 
posture,  and  leave  the  case  pretty  much  to  na- 
ture—  avoiding  everything  tending  to  internal 
stimulation.  Whilst  insensible,  we  examine  the 
wound  thoroughly,  using  the  finger  as  a  probe; 
and  if  any  loose  speculse  of  bone  be  felt  quite 
free  in  the  wound  unconnected  with  the  soft 
parts,  they  should  be  removed.  If  attached,  they 
must  be  left  to  escape  spontaneously  after  sup- 
puration is  established. 

Gunshot  fractures  are  usually  distinctly  limited 
to  the  portion  struck,  and  seldom  ramify  as  do 
fractures  from  diffused  blows.  It  is  this  concentra- 
tion of  the  force  within  a  small  compass,  and  the 
extended  injury  to  the  inner  tablet  of  the  skull, 
which  render  gunshot  injuries  of  the  head  so 
serious.  When  we  are  satisfied,  from  a  careful 
examination  of  the  condition  of  the  bones,  that 
they  remain  in  their  normal  position  without  de- 


252  TREATMENT    OP    FRACTURE    OF    SKULL. 

pression,  the  head  is  shaved  and  the  wound  care- 
fully closed  with  a  strip  of  adhesive  plaster,  so  as 
to  exclude  air.  As  soon  as  the  patient  has  revived, 
the  cold  water  or  ice  treatment  is  at  once  insti- 
tuted. Should  there  have  been  but  little  shock 
from  the  injury,  these  wet  applications  should 
be  commenced  with  on  the  battle  field. 

When  the  patient  is  put  to  bed  (which  should 
be  as  soon  as  possible,  for  early  treatment  is  all- 
important),  his  head  and  shoulders  should  be 
elevated;  quiet  and  absolute  rest  should  be  strict- 
ly enjoined;  the  room  should  be  darkened;  all 
stimuli,  including  light  and  noise,  should  be 
avoided;  the  bowels  should  be  freely  opened  by 
a  saline,  mercurial,  or  aloetic  cathartic;  and  for 
a  few  days,  abstemious  diet  prescribed.  These 
precautions  are  necessary  to  prevent  irritation  of 
the  brain,  with  subsequent  congestion,  inflamma- 
tion, and  effusion.  If  the  patient  appears  irrita- 
ble and  peevish,  without  heat  of  head  or  fulness 
of  pulse,  give  opium  to  quiet  him. 

The  case  should  be  watched  with  care,  and  if 
symptoms  of  congestion  of  the  brain  threaten, 
with  injection  of  the  face,  red  eyes,  hot  skin,  forci- 
ble throbbing  of  the  carotids,  increasing  head- 
ache, with  an  early  tendency  to  delirium,  the 
patient  should  be  at  once  bled,  the  head  should 


TREATMENT    OF    FRACTURE    OF    SKULL.  253 

be  shaved,  and  an  ice  bladder  be  assiduously 
applied  over  the  entire  scalp;  the  intestines  should 
be  freely  acted  upon  for  the  revulsive  effect 
upon  the  brain,  and  for  a  similar  reason,  sina- 
pisms should  be  applied  to  the  legs  and  thighs. 
Should  relief  not  be  promptly  obtained,  leeches  or 
cups  might  be  applied  to  the  mastoid  processes. 
Calomel  was  formerly  the  universal  prescription 
for  threatening  cerebral  inflammation.  Salivation 
was  induced  as  early  as  possible,  and  when  the 
system  was  brought  under  its  influence,  the  pa- 
tient was  considered  comparatively  safe.  In 
modern  surgery,  calomel  has  lost  its  high  posi- 
tion, and  the  dependence  upon  its  salivating 
powers  is  annually  diminishing.  Many  still  ad- 
minister it,  but  not  with  the  confidence  of  former 
times. 

Should  this  threatened  inflammation  not  sub- 
side under  this  course  of  treatment,  but  after  a 
period  of  high  febrile  excitement  the  delirium 
becomes  merged  into  stupor,  with  noisy  breath- 
ing, dilated  pupils,  slow,  labored  pulse,  relaxed 
sphincters  and  paralysis,  the  case  indicates  com- 
pression from  effusion,  within  or  upon  the  brain, 
and  chances  for  life  become  very  doubtful.  Per- 
haps, a  thick  layer  of  lymph  may  have  formed 
upon  the  cerebral  surface,  or  a  quantity  of  serous 


254  TREATMENT    OF    FRACTURE    OF    SKULL. 

fluid  collected  in  the  ventricles,  or  a  circumscribed 
or  diffused  abscess  in  or  upon  the  brain.  This 
lymph}-  effusion  sometimes  covers  the  entire  sur- 
face of  one  or  both  hemispheres.  The  arachnoidal 
membrane  appears  to  be  the  one  chiefly  inflamed. 
It  is  thickened,  semi  opaque,  adherent  to  the 
brain  surface,  and  reddened  in  patches.  The  pia 
mater  and  brain  substance  is  highly  injected. 

If,  with  the  occurrence  of  these  symptoms,  the 
patient  be  seized  with  chills,  the  scalp  wound 
becoming  dry,  and  the  tissues  puffy,  or  a  collec- 
tion forms  under  the  periosteum,  lifting  this 
membrane  from  the  bones  which  appear  dry  and 
yellow,  it  would  indicate,  in  many  instances,  a 
circumscribed  collection  of  pus  within  the  skull. 
These  symptoms  might  be,  but  very  rarely  are, 
relieved  by  the  use  of  the  trephine  As  a  gene- 
ral rule,  the  operation  hastens  the  fatal  catas- 
trophy.  Unless  an  external  abscess,  with  the 
characteristic  puffy  scalp,  defines  the  collection 
of  effusions  within,  the  trephine  should  not  be 
used.  It  often  happens  after  trephining,  that 
these  supposed  collections  have  not  been  found, 
and  it  is  only  after  the  operation  that  the  secre- 
tion of  pus  has  been  established.  When  air  is 
admitted,  suppuration  is  certain ;  whilst  without 
the  operation  the  effusions  are   known,  in  many 


INTERNAL    HEMORRHAGE.  255 

instances,  to  have  been  absorbed — the  patient 
recovering  after  remaining  insensible,  in  one  case, 
as  long  as  twenty-one  days. 

Cole,  in  his  Military  Surgery,  mentions  cases  of 
fracture  of  the  skull  from  ball,  without  the  skin 
being  torn.  Unless  the  bones  are  much  detached, 
as  they  were  in  one  of  his  cases,  the  condition 
can  only  be  suspected.  Such  injuries  must  be 
treated  under  the  antiphlogistic  expectant  plan. 
Await  symptoms  before  active  surgical  interference  is 
instituted,  and  ire  will  never  regret  it. 

There  are  a  series  of  cases,  in  which  injury  to 
the  skull  is  complicated  with  internal  bleeding. 
The  insensibility  which  seized  the  patient  at  the 
moment  of  injury  will  pass  off,  and  the  con- 
sciousness will  be  regained,  but  only  for  a  time. 
The  patient,  after  a  longer  or  shorter  interval, 
feels  heavy  and  dull,  and  indisposed  to  exertion; 
finally,  a  strong  disposition  to  sleep  comes  over 
him,  which,  deepening  into  coma,  ends  in  all 
the  symptoms  of  well  marked  compression.  This 
is  an  instance  in  which  the  surgeons,  of  twenty 
years  since,  would  have  trephined,  as  the  only 
chance  of  saving  the  patient.  jS"ow,  we  would  lay 
down  an  equally  broad  rule,  that  his  only  hope  of 
recovery  is  in  avoiding  the  trephine.  Pursue 
a   rigid   antiphlogistic   course;    free    venesection,. 


256  TREPHINE    USELESS. 

when  assisted  by  ice  bladders  to  the  entire 
scalp,  will  stop  further  loss  of  blood,  reduce 
the  action  of  the  heart,  and  permit  the  effused 
blood  to  clot,  so  as  to  close  the  openings  in 
the  torn  blood-vessels ;  then,  by  free  purga- 
tion, act  upon  the  bowels,  both  for  a  deriva- 
tive effect,  and  to  promote  the  absorption  of 
the  effusion.  If  you  can  stop  the  further  escape 
of  blood,  that  which  has  been  effused  will  gra- 
dually be  removed,  and  the  symptoms  of  com- 
pression will  as  gradually  pass  off,  after  having 
coutinued  for  days,  or  even  weeks.  Trephine 
such  a  patient,  and  what  certainty  have  we  that 
we  will  find  the  point  where  hemorrhage  has 
taken  place,  or  that  the  blood  is  still  fluid,  and 
can  be  removed — both  very  improbable  results. 
Blood-vessels  may  have  given  way  at  any  other 
portion  of  the  brain  than  at  the  portion  corre- 
sponding to  the  point  where  the  skull  is  injured. 
The  recoil  of  the  contents  of  the  skull  may  have 
ruptured  vessels  diametrically  opposite  to  the  in- 
jured point.  Autopsies  not  unusually  reveal  such 
conditions. 

The  operation  of  trephining  is  always  very 
serious  2)er  se,  aQd  is  sufficient  of  itself  to  cause 
cerebral  or  meningeal  inflammation,  which  will 
nearly  always  terminate  fatally.  The  operation  is 
often  more  serious  than  the  condition  for  which  it 


FRACTURE  WITH  DEPRESSION.  257 

is  used,  and,  although  the  patient  might  recover 
from  either,  he  succumbs  under  the  combination. 
Experience  and  autopsies  have  shown  us  many 
cases  of  extensive  intra-cranial  hemorrhages,  which 
have  been  unaccompanied  by  symptoms  denot- 
ing such  an  accident;  and  the  traces  of  such  have 
been  found  when  the  patient,  recovering  from  his 
head  injury,  had  fallen  a  victim  to  some  totally 
foreign  disease.  Had  such  a  condition  been  sus-' 
pected,  and  the  surgeon  used  his  instruments,  an 
autopsy  at  a  much  earlier  day  would  have  re- 
vealed the  condition. 

The  third  variety  of  injury  of  the  head,  with  depres- 
sion of  the  skull,  belongs  to  a  more  serious  class  of 
wounds.  The  complication  is  detected  at  once  by 
examining  the  wound  with  the  finger,  when  the 
sinking  of  the  bones  is  felt,  the  extent  of  injury  is 
detected,  and  the  condition  of  the  depressed  por- 
tion, whether  en  masse  or  spiculated,  determined. 
The  broken  fragments,  if  quite  loose,  should  be 
removed  within  the  first  twenty-four  hours,  before 
reaction  sets  in.  When  concussion  has  passed  off, 
and  no  symptoms  exist  indicating  injurious  pres- 
sure upon  the  brain,  the  case  should  be  treated  in 
every  respect  as  if  no  depressed  fragments  existed. 
Unless  wre  see  clearly  that  the  bone  is  very  much 
spiculated,  and  that  sharp  fragments  are  piercing 
22 


258  FRACTURE  WITH  DEPRESSION. 

the  meninges,  avoid  all  instrumental  interference, 
even  to  dilating  the  wound,  for  the  purpose  of 
facilitating  a  more  accurate  diagnosis. 

We    should     never    be     anxious     to     see    the 
symptoms    of   concussion    rapidly    disappear ;    let 
nature  abide  her  time ;  watch  the  case  and  see  that 
the  patient  suffers  no    detriment.     Examine   fre- 
quently the  pulse,  but  not  the  head,  and  as  long 
as  it  sustains  itself,   everything  is  working  to  the 
advantage   of  the  wounded.      By  rapid   reaction 
torn    blood-vessels   may   not    have   had   time    to 
become   plugged    up,    and    internal   hemorrhage, 
which  is  always  serious,  might  ensue.     As  soon 
as    the    pulse   commences   to   improve,    then  we 
commence  cold  applications,  which,  if  assiduous- 
ly   applied,    may    prevent    the    after-venesection. 
When    bloodletting   is  required,    it  is   preferable 
to  bleed  moderately  from  a  large  opening,  to  be 
repeated,  if  necessary.     The  object  is  to  obtain  its 
sedative   and   revulsive    effect,  and  to  despoil  to 
as  limited  an  extent  as  possible.     If  from  six  to 
ten   ounces,   from   a   large  opening   in   the   vein, 
will   produce    a  sensible   feeling  of  faintness,   do 
not  draw  from  sixteen  to  twenty.     This  sedative 
effect  might  be  sustained  by  leeches  or   cups  to 
the    neck,   and   by    small    doses    of   tart,    emetic, 
veratrum    viride,    or    digitalis  —  never,    however, 


FRACTURE    WITH    DEPRESSION.  259 

pushing  these  remedies  to  vomiting,  which,  by 
tending  to  congestion  of  the  head,  would  act  inju- 
riously. Revulsives  to  the  intestines,  as  recom- 
mended in  the  treatment  of  simple  fractures,  with 
ice  to  the  head,  are  the  remedies  upon  which  most 
reliance  is  to  be  placed.  Free  purgation  is  not 
desirable,  as  the  frequent  change  of  position  would 
be  injurious  to  the  patient.  Should  the  integu- 
ments and  pericranium  inflame  with  much  swell- 
ing, pain  and  tension,  with  febrile  reaction, 
incisions,  or  rather  scarifications,  may  be  made 
to  release  the  pent-up  fluids.  These,  if  possible, 
should  be  made  at  a  distance  from  the  seat  of 
fracture — the  object  being  to  protect  the  injured 
bones  from    atmospheric   influences. 

Surgeons  are  now  becoming  familiar  with  the 
fact  that  considerable  depression  may  exist  in 
the  external  tablet  of  the  skull  without  the  in- 
ternal being  fractured — the  external  layer  being 
driven  into  and  condensed  within  the  diploe. 
Also,  that  both  tablets  may  be  depressed,  com- 
pressing the  brain,  without  causing  harm  at  any 
subsecpuent  period.  Observation  has  multiplied 
these  cases  to  such  an  extent  as  to  modify 
the  entire  treatment  of  head  injuries.  Although 
the  cranial  cavity  is  tilled  with  brain,  its  con- 
tents  are    continually    undergoing   changes   from 


260  FRACTURE    WITH    DEPRESSION. 

the  excessive  vascularity  of  the  hrain  substance, 
and,  also,  from  the  free  communication  which 
exists  between  the  fluid  filling  the  ventricles 
and  the  veinous  plexus  which  abound  in  the 
brain.  By  diminishing  the  blood  and  wrater  in 
the  brain,  accommodation  can  be  made  for  the 
depressed  bone.  As  a  general  rule,  in  gunshot 
wounds,  with  depression  of  fragments,  no  re- 
markable symptoms  exhibit  themselves,  until 
there  is  a  determination  of  blood  to  the  head 
from  reaction,  from  mental  or  bodily  excitement. 
Rational  practice  would  lead  us  to  combat 
the  tendency  to  congestion  by  rest,  quiet,  cold 
revulsives  and  venesection,  rather  than  by  the 
trephine,  which  experience  has  shown  to  be  so 
unprofitable.  Opium  is  now  used  with  much 
greater  freedom  in  the  treatment  of  injuries  of 
the  head  than  formerly  and,  when  administered 
with  discretion,  will,  to  a  certain  extent,  take 
the  place  of  trephining.  Whenever  the  patient  is 
restless,  sleepless,  and  irritable  with  delirium, 
should  the  face  not  be  red,  nor  head  hot,  it  can 
be   used  with  safety  and  benefit. 

When  suppuration  is  established  in  the  wound, 
and  granulations  commence  to  form,  those  por- 
tions of  bone  which  cannot  be  saved,  will  gra- 
dually  become    detached    and    will    escape.      A 


FRACTURE    WITH    DEPRESSION.  261 

tendency  to  bleeding:  in  the  granulations  of  the 
wound  is  an  indication  that  the  fragments  of 
bone  have  become  loose  and  are  ready  to  be 
removed.  This  symptom,  which  is  a  valuable 
one,  must  be  noted. 

The  fourth  variety  of  injury  to  the  head,  inhere  a 
compound  fracture,  with  depressed  fragments,  is  con- 
nected with  symptoms  of  compression,  is  a  very  seri- 
ous accident,  and  is  the  only  variety  of  compli- 
cated head  wound  in  which  surgeons  consider 
instrumental  interference  called  for.  Even  in 
this  instance,  the  propriety  of  trephining  is 
doubted  by  many  of  large  experience,  although 
no  doubt  exists  that,  in  some  cases,  immediate 
relief  has  followed  the  lifting  of  the  depressed 
bone.  It  is  said,  that  the  successful  treatment 
of  such  cases  will  depend  more  upon  the  condi- 
tion of  the  brain  and  membranes  than  merely 
upon  the  depression.  Should  these  be  lacerated, 
or  in  any  way  injured,  inflammation  will  sooner 
or  later  show  itself.  The  operation  of  trephin- 
ing, under  such  circumstances,  would  increase  the 
local  irritation,  expose  the  injured  tissues  to 
injurious  atmospheric  influences,  and  hasten  on 
a  violent   and   usually  fatal   inflammation. 

If  the   brain   and    membranes  be  not   injured, 


262  FRACTURE  WITH  DEPRESSION. 

then  it  is  said  that  the  brain  will  soon  become 
accustomed  to  the  pressure,  and,  although  in- 
sensibility may  continue  for  hours,  days,  or,  as 
in  many  instances  of  ultimate  recovery,  for  weeks, 
the  symptoms  of  compression  will  gradually  pass 
off*.  By  not  using  instruments,  the  surgeon  has 
the  satisfaction  of  knowing  that  he  has  not 
increased  the  local  trouble  by  a  serious  opera- 
tion. The  removal  of  the  symptoms  of  com- 
pression being  very  gradual,  excessive  reaction 
is  not  likely  to  follow,  and  as  no  air  has  been 
admitted  to  the  effusions  beneath  the  skull,  the 
probability  of  suppuration  will  be  much  dimin- 
ished. When  effusions  have  taken  place,  the 
depressed  bone  acts  as  a  covering,  excluding  air 
with  its  injurious  chemical  influences.  Fluids, 
uncontaminated  by  decomposition,  can  be  ab- 
sorbed. When  the  skull  is  opened,  and  the  free 
admission  of  air  is  permitted,  suppuration,  with, 
perhaps,  pyeemia,  is  prone  to  occur. 

Stromyer,  who  is  one  of  the  highest  authorities 
on  gunshot  wounds  of  the  head,  and  who,  as 
surgeon-in-chief  of  the  Schleswig-Holstein  army, 
had  every  facility  for  studying  his  favorite 
branch  of  surgery,  gives  us  as  the  result  of  his 
experience,  observation  and  study,  that  the  tre- 
phine can  be  abandoned  in  military  surgery.     In 


FRACTURE    WITH    DEPRESSION.  263 

a  supplement  to  his  work  on  Military  Surgery, 
recently  published,  he  states,  "that  in  military 
surgery  trephining  is  never  needed. — When  the  case 
is  so  severe  as  to  require  the  trephine  in  gunshot 
wounds,  the  patient  will  die  in  spite  of  it." — In 
the  last  two  campaigns,  in  which  he  had  charge  ot 
the  army,  he  has  not  trephined.  Loeffler,  a  dis- 
tinguished surgeon  in  the  Prussian  service,  who 
has  published  one  of  the  best  books  of  instruc- 
tion for  military  surgeons,  after  acknowledging 
Stromyer  as  the  master  in  all  relating  to  the 
treatment  of  gunshot  wounds  of  the  head,  en- 
dorses his  views  in  opposition  to  trephining. 

McLeod  gives  the  following  as  the  Crimean 
experience: — "As  to  the  use  of  the  trephine — the 
cases  and  time  for  its  application — less  difference 
of  opinion,  I  believe,  exists  among  the  experi- 
enced army  surgeons  than  among  civilians;  and  T 
think  the  decided  tendency  among  them  is  to 
endorse  the  modern  'treatment  by  expectancy,' 
and  to  avoid  operating  except  in  rare  cases.  In 
this,  I  believe  they  judge  wisely;  for  when  we 
examine  the  question  carefully,  we  find  that  there 
is  not  one  single  indication  for  having  recourse  to 
operations,  which  cannot,  by  the  adduction  of 
pertinent  cases,  be  shown  to  be  often  fallacious." 
Hewett,  in  a  series  of  lectures  on  injuries  of  the 


264  FRACTURE    WITH   DEPRESSION. 

.  head,  published  in  the  Medical  Times  and  Gazette 
for  1859,  which  form  the  most  complete  treatise 
i  extant  on  the  subject,  is  equally  adverse  to  the 
trephine.  Guthrie,  Cole,  and  Williamson,  in 
their  reports,  equally  confirm  the  dangers  of  the 
trephine,  and  the  great  fatality  accompanying  its 
use. 

The  entire  records  of  the  science  may  be 
searched  in  vain,  to  find  a  duplicate  series  of 
successful  cases  to  that  reported  by  Stromyer. 
Of  forty-one  cases  of  fracture,  with  depression 
from  gunshot  wounds,  in  many  of  which  it  was 
probable  that  the  brain  and  membranes  were  in- 
jured, only  seven  died — all  the  rest  recovered.  In 
only  one  case  was  there  any  operative  interfer- 
ence, although  signs  of  secondary  compression  appear- 
ed in  several.  The  antiphlogistic  treatment,  carefully 
carried  out,  was  alone  adhered  to. 

No  surgeon  can  doubt  that  the  operation  of 
trephining  has  cost  many  a  man  his  life,  and 
although  many  cases  have  recovered  after  the 
operation,  it  is  a  question  whether,  in  the  major- 
ity of  cases,  more  rapid  recovery  would  not 
have    been  obtained  without  it. 

When  symptoms  of  compression  ensue  in  the 
course  of  treatment,  continue  the  steady,  onward 
use    of   antiphlogistic   remedies.      At   this  June- 


FRACTURE    WITH   DEPRESSION.  265 

ture,  many  surgeons  recommend  calomel  pushed 
to  salivation,  which  some  state  to  be  synonymous 
with  salvation.  There  is  no  unanimity,  however, 
on  this  head;  the  modern  tendency  is  to  treat 
such  cases  without  the  use  of  mercury. 

When  balls  penetrate  or  perforate  the  cranium, 
the  detached  piece  of  bone  is  driven  before  the 
ball  into  the  substance  of  the  brain.  The  resist- 
ance which  the  ball  meets  changes  its  course, 
and  glancing  from  the  depressed  fragment,  it 
takes  a  different  direction,  burying  itself  in 
the  brain  at  some  distance  from  the  piece  of 
bone.  In  by  far  the  majority  of  cases,  death 
is  instantaneous,  or  soon  follows  the  receipt 
of  injury.  There  are,  nevertheless,  a  few  ex- 
ceptions to  this  rule,  in  which  the  patient, 
recovering  from  the  shock  and  sequelae,  has 
carried  the  ball  or  other  missile  in  his  brain  for 
years;  and,  eventually  dying  of  some  disease  un- 
connected with  the  head,  an  autopsy  reveals 
the  ball  embedded  in  the  brain,  and  surrounded 
by  a  mass  of  lymph.  Of  ninety-one  cases  of 
penetrating  and  perforating  gunshot  wounds  of 
the  head  which  were  admitted  into  hospital  in 
the   Crimea,   all,  without  exception,  proved  fatal. 

When    the   openings  are  examined,  it  will  be 
found  that  the  hole  made  in  the  outer  tablet  is 
23 


266  FRACTURE    WITH    DEPRESSION. 

more  or  less  smooth,  whilst  the  orifice  in  the 
inner  tablet  is  much  more  extensively  fractured, 
and  usually  much  spiculated.  This  condition  of 
the  orifices  is  owing  more  to  the  direction  of  the 
blow  than  from  any  supposed  brittleness  in  the 
inner  tablet;  for,  should  the  ball  traverse  from 
within  outward,  the  reversed  condition  is  found. 
It  would  be  folly  to  attempt  the  search  after 
such  foreign  bodies  for  the  purpose  of  removing 
them,  as  such  a  piece  of  meddlesome  surgery 
wTould  ensure  a  fatal  issue,  whatever  hope  of 
recovery  might  have  been  entertained.  We  have 
heard  of  such  an  instance,  where  a  physician 
had  probed  the  brain  with  a  silver  probe  to  find 
a  ball,  but  hope  never  to  see  such  a  piece  of 
barbarous  ignorance. 

Cole,  in  his  Indian  Reports,  mentions  "  that 
there  are  many  soldiers  now  doing  duty  in  our 
ranks,  for  whom  (having  been  wounded  in  their 
heads  during  the  late  war)  the  medical  officers 
had  not  the  smallest  hope;  and  every  military 
surgeon,  who  has  had  much  practice  in  the  field, 
has  learned  not  to  despair  so  long  as  life  remains." 
The  thorough  probing  of  such  cases,  to  satisfy  the 
curiosity  of  a  surgeon,  would  soon  have  destroyed 
all  hope  with  the  life  of  the  patient. 

The  general  treatment  of  such  cases  should,  in 
no  wise,  differ  from  that  laid  down  for  the  treat- 


FRACTURE  WITH  DEPRESSION.  267 

ment  of  head  injuries  in  general.  The  concus- 
sion and  compression,  which  are  well  marked  and 
always  present,  must  he  met  with  all  the  precau- 
tions already  pointed  out. 

We  might  iioav  sum  up,  in  a  few  words,  the 
rational  and  successful  treatment  of  gunshot 
wounds  of  the  head.  In  concussion,  unless  there 
is  evident  sinking,  leave  the  case  to  nature,  and 
avoid,  studiously,  both  stimulation  and  venesec- 
tion. When  the  patient  is  restored  to  conscious- 
ness, should  inflammation  of  the  brain  threaten, 
if  there  he  no  congestion  of  the  face,  give  opium 
to  alia}'  irritation.  Should  congestion  be  evi- 
dent, use  the  antiphlogistic  treatment  locally  and 
generally,  commencing  with  venesection,  and  with 
ice  applications  to  the  head.  In  every  case, 
absolute  quiet  and  rest-  are  essential.  For  the 
want  of  a  proper  sentinel  at  the  door  of  the  ward 
in  which  head  injuries  are  being  treated,  many 
cases  have  been  lost.  All  gunshot  injuries  of  the 
head  are  serious,  however  trivial  they  may  ap- 
pear, inasmuch  as  violent  inflammation  often  fol- 
lows slight  wounds;  all,  therefore,  should  be 
carefull}'  watched. 

Chronic  ostitis  or  periostitis,  resulting  from  gun- 
shot wounds,  possesses  no  peculiarity,  and  should 
be  combated  by  iodide  of  potassium. 


CHAPTER    VIII. 

Wounds  of  the  Face — Fractures  of  the  upper  and 
lower  jaw — Wounds  of  the  neck — Large  vessels 
avoid  the  perforating  ball —  When  large  arteries  in 
the  neck  are  divided,  the  necessity  of  ligating  the 
bleeding  mouths. 

Wounds  of  the  Face,  when  they  do  not  im- 
plicate the  brain,  are  not  usually  of  a  serious 
character.  The  severe  cuts  about  the  face,  made 
by  the  sabre  or  by  pieces  of  shell,  should  be  treat- 
ed for  adhesion  by  the  first  intention.  The  lips 
should  be  brought  together  by  sutures,  and  cold 
water  dressings  will  complete  the  cure.  The  ex- 
cessive swelling,  which  accompanies  many  inju- 
ries of  the  face,  especially  gunshot  wounds  and 
burns  from  explosion  of  powder,  is  rarely  con- 
trolled by  cold  water  dressings.  It  runs  its 
harmlesss  course,  moderated  by  the  cold  applica- 
tions, and  subsides  at  the  end  of  a  few  days.  In 
the  Italian  campaign,  I  saw  cases  in  which  Min- 
nie balls  had  traversed  the  breadth   of  the  face, 


WOUNDS   OF   THE    FACE.  269 

passing  through  each  molar  bone,  without  leav- 
ing any  injurious  sequela?.  The  rapidity  with 
which  all  wounds  of  the  face  heal  has  often  been 
remarked. 

The  most  common  injuries  to  the  face  from 
gunshot  wounds  are  fractures  of  the  upper  and 
lower  jaws.  Balls  often  become  embedded  in 
the  soft,  spongy  bones  of  the  face,  and,  if  not 
discovered  in  time,  are  discharged  spontaneously. 
When  the  bones  of  the  face  are  struck  by  a  grape- 
shot,  or  a  flattened  conical  ball,  there  may  be 
great  destruction  of  the  features,  followed  by 
shocking  deformity. 

The  senses  are  not  unfrequently  destroyed — 
sight  or  smell  being  often  impaired,  if  not  com- 
pletely lost  after  gunshot  injuries.  "Where  the 
wound  has  been  received  in  the  orbit,  the  loss 
of  vision  is  not  only  very  probable,  but  there  is 
great  fear  that  the  cause  producing  the  injury, 
whether  it  be  a  ball,  bayonet,  or  a  sword  point, 
may  have  perforated  the  thin  plate  of  the  skull, 
entered  the  brain  and  may  induce  cerebral  in- 
flammation. Many  cases  of  apparently  trivial 
wounds  of  the  eyelids  have  terminated  fatally, 
and  an  autopsy  revealed  serious  injury  to  the 
anterior  lobes  of  the  brain  and  its  enveloping 
membranes.       Such    cases    should     be     carefully 


270  WOUNDS    OP    THE    PACE. 

watched,  and  any  cerebral  symptoms,  which  may 
arise,  should  be  actively  met  by  the  antiphlogistic 
treatment,  headed  by  venesection. 

From  the  great  vascularity  of  all.  the  structures 
composing  the  face,  we  would  expect  to  have 
serious  hemorrhage  accompanying  all  injuries — 
for  controlling  which,  the  astringents  of  iron  will 
be  frequently  required.  The  vessels  are  so  nu- 
merous that  the  direct  application  of  ligatures 
cannot  be  made.  In  fractures  of  the  upper  jaw, 
the  bones  are  always  more  or  less  spiculated^ 
with  one  or  more  teeth  loosened  or  completely 
detached.  As  all  portions  are  freely  supplied 
with  blood-vessels,  union  will  take  place  among 
the  fragments,  even  after  considerable  shattering 
of  the  bones.  Unless  the  fragments  are  either 
completely  detached  or  but  slightly  adherent, 
they  should  not  be  taken  away,  but  should  be 
replaced  with  care,  as,  in  time,  consolidation  may 
take  place  and  very  little  permanent  deformity 
will  be  left.  Should  some  of  these  fragments  die, 
they  will  be  found  loose,  often  as  early  as  the  sixth 
or  eighth  day,  and  should  be  removed.  The 
cold  water  dressings,  to  relieve  the  excessive 
swelling,  with  an  occasional  dose  of  salts,  is  the 
only  medication  required.  The  wound  in  the  face 
should  be  closed  with  adhesive  plaster,  and,  after 


WOUNDS    OF    THE    FACE.  271 

careful  adjustment  of  the  movable  fragments, 
and  the  use  of  cold  water  dressings  for  a  few 
days,  the  case  is  left  pretty  much  to  nature. 

When  the  soft  parts,  as  wTell  as  the  bones,  are 
crushed,  secondary  hemorrhage  frequently  recurs, 
as  the  sloughing  tissues  come  away.  Formerly, 
the  difficulty  of  restraining  this  loss  of  blood  wras 
so  great  as  to  require,  in  many  cases,  the  ligation 
of  the  main  vessels  in  the  neck.  We  now  find 
the  thorough  application  of  the  per-chloride  or 
per-sulphate  of  iron  an  efficient  remedy.  Should 
necrosis  follow  injuries  to  the  bones  of  the  face, 
the  dead  pieces  of  bone  should  be  removed  as 
they  become  loosened,  or  a  special  operation  may 
be  undertaken  for  ridding  the  face  of  the  local 
cause  of  trouble. 

Fractures  of  the  lower  jaw  are  not  a  rare  ac- 
cident on  the  battle  field,  whether  from  shot 
wounds  or  other  accidents.  At  times,  the  entire 
jaw  may  be  swept  off  by  a  round  shot,  leaving  the 
mouth  and  throat  exposed.  One  of  the  most 
fearful  cases  on  record  is  one  in  which  the  en- 
tire face  was  carried  away  by  a  cannon  ball, 
leaving  nothing  but  the  skull  proper,  appended 
to  the  vertebral  column.  The  opened  gullet 
marked  the  former  site  of  the  features.  The 
patient   lived  ten  hours,  and  from   the   frequent 


272  WOUNDS   OF   THE    FACE. 

change  of  position,  and  the  squeezing  of  the 
hand  when  his  was  taken,  it  was  thought  that 
consciousness  remained  up  to  the  time  of  death. 
The  surgeon  accompanying  the  transport  usually 
sends  injuries  of  the  face  to  the  field  infirmary 
untouched,  or,  should  the  lower  jaw  be  broken, 
applies  a  folded  handkerchief  or  band  under  it  to 
support  it.  It  is  permanently  put  up  in  a  paste- 
board splint,  well  padded  with  carded  cotton,  and 
secured  by  a  folded  cloth  or  double-tailed  ban- 
dage. One  band  passes  over  the  vertex,  sup- 
porting the  jaws,  whilst  the  other  passes  from 
the  front  of  the  chin  behind  the  head,  and  then 
around  the  forehead,  where  it  is  secured  by  pins. 
Before  the  dressings  are  applied,  the  wounds 
should  have  been  examined  carefully  with  the 
finger,  and  all  perfectly-detached  spicuhe  of  bone 
should  have  been  removed.  The  surgeon  must 
be  prepared  to  meet  much  swelling  and  profuse 
salivation.  All  wounds  of  the  bones  of  the  face 
being  compound,  suppuration  is  soon  established, 
and  the  secretion  of  pus  is  copious.  It  will  add 
much  to  the  comfort  of  the  patient  if  his  mouth 
be  swabbed  out  daily  with  a  piece  of  soft  rag  or 
sponge  attached  to  a  thin  piece  of  wood.  From 
the  difficulty  in  swallowing,  fluid  nourishment 
must  be  prescribed.     The  constant  thirst  of  those 


WOUNDS    OF    THE    NECK.  Z7d 

wounded  will  be  relieved  by  small  doses  of  mor- 
phine, or  by  acidulated  drinks,  made  either  with 
diluted  nitric  acid  or  vinegar.  Injuries  about  the 
face  are  very  liable  to  erysipelatous  attacks.  The 
treatment  by  the  tincture  of  the  muriate  of  iron, 
locally  and  generally,  will  stop  its  progress. 

Wounds  of  the  neck,  with  injury  to  the  numerous 
large  vessels  which  course  through  this  con- 
stricted region,  are  among  the  serious  accidents 
in  battle.  From  the  anatomy  of  this  region,  we 
would  suppose  that  a  missile  could  not  traverse 
the  neck  in  any  direction  without  destroying  some 
important  part,  nerve  or  artery.  We  find,  after 
every  great  battle,  perforations  by  balls  in  every 
direction,  accompanied  by  violent  hemorrhages; 
yet,  with  the  first  fainting  brought  on  from  shock 
and  loss  of  blood,  we  find  a  spontaneous  cessa- 
tion of  the  bleeding,  and  the  onward  progress  of 
the  case  becomes  one  of  continued  convalescence, 
to  perfect  cicatrization.  I  have  seen  conical  balls 
perforate  the  neck  antero-posteriorly,  entering  just 
above  the  sterno-clavicular  junction,  and  passing  in 
the  midst,  if  not  through,  the  largest  vessels  of  the 
body,  without  producing  a  fatal  hemorrhage.  I 
have  also  seen  them  perforate  the  throat  laterally, 
on  a  level  w7ith  and  just  behind  the  angle  of  the 


274  WOUNDS    OP   THE    NECK. 

lower  jaw,  and  a  cure  equally  follow.  It  is 
wonderful  how  the  great  vessels  escape,  or  the 
rapidity  with  which  clots  form  and  the  wounds  of 
such  vessels  close.  McLeod  reports  one  hundred 
and  twenty-eight  cases,  more  or  less  severely 
injured  in  the  neck,  with  but  four  deaths.  Many, 
to  be  sure,  die  on  the  battle  field  in  a  few 
moments  after  receiving  a  serious  injury  to  the 
large  arteries ;  but,  undoubtedly,  many  also  re- 
cover. 

The  powerful  iron  styptics  are  the  only  local 
remedies  applicable  on  the  battle  field,  as  the 
patient  could  not  otherwise  bear  the  transporta- 
tion ;  and  the  assistant  surgeon,  following  the 
troops,  has  neither  the  time  nor  conveniences  for 
ligating  the  bleeding  mouths  of  the  divided  ves- 
sel, however  urgently  it  may  be  called  for,  to 
save  life.  The  precautions  which  were  urged  in 
discussing  the  means  of  arrest  of  hemorrhage  in 
wTounds  generally  must  here  be  carefully  applied  ; 
and  should  secondary  hemorrhage  occur,  and  be 
renewed,  notwithstanding  the  careful  application 
of  the  iron  styptic,  the  safety  of  the  patient 
will  then  lie  only  in  the  ligation  of  both  bleed- 
ing orifices.  The  anastomosis  is  so  free  in  the 
neck,  that  all  other  operations  will  be  futile, 
and   the   patient   will   perish.      A  ligature    upon 


WOUNDS    OF    THE    NECK.  275 

the  carotid  artery,  both  above  and  below  the 
wound,  has  been  reported  a  failure  in  control- 
ling a  hemorrhage,  which  was  only  checked  by 
dilating  the  wound  and  ligating  the  artery  at  the 
point  injured.  In  enlarging  the  wound,  the  in- 
cision will  always  be  made  parallel  with  the  axis 
of  the  neck,  so  as  to  avoid  injuring  important 
nerves  or  blood-vessels. 


CHAPTER    IX. 

Wounds  of  the  Chest — Flesh  wounds — Effusions  within 
the  cavity  when  the  pleura  is  injured — Wounds  of 
the  heart  or  lung  —  A  transfixed  chest  does  not 
necessarily  imply  a  perforated  lung  —  Diagnostic 
value  of  the  various  symptoms — Hcemoptysis,  Dysp- 
noea, Collapse,  Emphysema  —  Treatment  of  chest 
wounds — How  inflammatory  complications  are  to  be 
combated — The  treatment  of  a  fractured  rib. 

Wounds  of  the  Chest,  when  taken  as  a  class, 
are  perhaps  the  most  fatal  of  gunshot  wounds. 
Many  are  shot  down,  and  die  more  or  less  rapidly 
on  the  battle  field  from  internal  hemorrhage,  with 
its  accompanying  suffocation,  and  are  returned 
among  the  killed.  Fraser,  in  an  excellent  trea- 
tise on  chest  wounds,  based  upon  data  obtained 
in  the  Crimea,  states  the  mortality  to  have  been 
twenty-eight  per  cent,  of  all  chest  wounds,  and 
seventy-nine  per  cent,  of  those  in  which  the  lung 
had  been  injured.  The  Russian  report  gives  as 
their  mortality  in  chest  wounds    ninety-eight  per 


FLESH   WOUNDS    OF   CHEST.  277 

cent.,  which  is  sufficient  proof  of  their  serious 
character.  The  danger  in  wounds  of  the  thorax 
is  from  visceral  complications.  Should  the  lung 
be  severely  injured,  the  case  usually  terminates 
fatally. 

From  the  peculiar  formation  of  the  thoracic 
box  and  the  curve  of  the  ribs,  balls,  in  striking, 
are  often  deflected  from  the  straight  line,  and,  after 
a  longer  or  shorter  course,  escape  without  having 
penetrated  the  chest.  Often,  the  two  openings 
correspond  so  accurately  in  direction,  as  to  estab- 
lish a  strong  conviction  of  a  direct  passage 
through  or  across  the  thorax,  when  the  wound 
has  been  but  a  subcutaneous  one  throughout.  I 
have  seen  an  instance  in  which  a>  ball,  which  had 
entered  the  chest  just  below  the  left  armpit,  was 
removed  from  a  similar  position  in  the  right  side, 
and,  although  it  had  apparently  traversed  the 
thorax,  no  inconvenience  was  experienced;  its 
entire  course  had  been  subcutanoeus.  This  tor- 
tuous track  can  only  be  made  by  a  ball  striking 
at  a  considerable  obliquity.  Its  direction  is  gen- 
erally indicated  by  a  reddish  or  purplish  line 
under  the  skin,  which,  when  followed  by  the 
linger  pressed  on  the  surface,  imparts  a  crackling 
sensation,  caused  by  air  in  the  cellular  tissue. 
Such  injuries  are  usually  simple,  and  require  but 


278  PENETRATING    WOUNDS    OF    CHEST. 

little  treatment.  The  cold  water  dressing  tills 
every  indication,  and  its  application  for  a  few 
days  usually  effects  a  cure. 

A  great  amount  of  nervous  shock  often  accom- 
panies very  trivial  injuries  of  the  chest.  Many 
instances  are  mentioned  by  militar}^  surgeons  in 
which  halls  had  struck  articles  about  the  person 
of  the  soldier  —  the  breast-plate  of  a  cuirassier, 
or,  perhaps,  a  book  in  the  breast-pocket  of  a  sol- 
dier's coat — and  had  fallen  to  the  ground  without 
even  touching  the  skin,  yet  the  soldier  had  been 
knocked  down  breathless,  and,  in  some  cases,  did 
not  recover  completely  from  the  shock  for  days. 

When  the  ball  has  penetrated  the  chest,  it 
may  course  for  some  distance  between  the  ribs 
and  the  pleura,  when  it  may  either  escape  from 
the  cavity,  and  be  found  under  the  skin,  or 
remain  capped  by  the  pleura.  Such  cases  may 
give  no  trouble,  or  pleuritis  may  ensue,  winch  the 
rational  signs,  with  discultation,  will  detect,  and 
an  antiphlogistic  course,  accompanied  with  the 
free  use  of  opium,  will  readily  subdue.  Opium, 
when  used  in  large  doses,  frequently  repeated, 
possesses  other  virtues  than  merely  allaying  pain 
and  quieting  nervous  symptoms.  It  combats, 
directly,  inflammation,  and,  by  the  great  control 
which  it  exercises  over  the  brain  and  circulation, 


INFLAMMATORY   EFFUSIONS    IN    CAVITY.  279 

becomes  one  of  the  most,  if  not  the  most  valuable 
remedy  of  the  materia  medica  in  the  treatment  of 
the  serious  sequelre  of  wounds.  When  given  in 
combination  with  nitrate  or  carb.  of  soda,  its 
nauseating  effects  are  counteracted. 

The  evil  which  the  surgeon  fears  from  perfo- 
rating wounds,  followed  by  inflammation,  is  that 
a  serous,  or  sero-purulent  effusion  may  rapidly 
accumulate  in  the  thoracic  cavity,  and  destroy 
the  patient.  So  rapidly  is  this  fluid  formed,  in 
many  cases,  that  the  chest  has  been  known  to 
fill  in  twenty-four  or  forty-eight  hours,  the  fluid 
compressing  and  condensing  the  lung  against 
the  vertebral  column.  In  expanding  the  chest,  it 
will  be  found  that  as  soon  as  a  thin  layer  of  fluid 
is  effused  into  the  cavity,  separating  the  lung 
from  the  thoracic  wall,  the  respiratory  murmur 
becomes  very  feeble,  and  will  altogether  dis- 
appear when  the  cavity  is  filled.  At  the  same 
time  respiration  becomes  much  embarrassed  with 
marked  dyspnoea.  Percussing  the  side,  will  now 
give  a  dull,  heavy  sound,  instead  of  the  ordinary 
clear,  sonorous  one  of  health ;  and  the  position  of 
the  patient,  unless  the  cavity  is  filled  with  fluid, 
must  vary  the  sound  by  the  gravitation  of  the 
serous  collection.  The  lung  is  condensed  and 
flattened   against   the    vertebral    column,    and    is 


2S0  INFLAMMATORY   EFFUSIONS    IN    CAVITY. 

temporarily  impervious  to  air:  under  a  long  con- 
tinuance of  the  pressure,  it  will  become  per- 
manently consolidated.  The  increase  in  the 
circumference  of  the  chest,  and  the  fulness  of 
the  intercostal  spaces,  and  the  absence  to  a  great 
extent  of  respiratory  movements  upon  the  affect- 
ed side,  are  conspicuous  symptoms  of  a  distended 
cavity. 

The  quantity  of  fluid  thrown  out  varies  from 
a  few  ounces  to  several  pints.  When  the  na- 
tural dimensions  of  the  cavity  are  not  sufficient- 
ly extensive  to  accommodate  it,  it  forces  the 
mediastinum  over  to  the  sound  side,  interfering 
with  the  action  of  the  healthy  lung,  whilst  an 
encroachment  may  be  equally  made  upon  the 
abdomen. 

When  the  surgeon  has  recognized  such  collec- 
tions as  rapidly  forming  in  the  chest  after  gunshot 
wounds,  accompanied  by  distressing  symptoms 
of  dyspnoea,  an  early  evacuation  will  be  re- 
quired. Should  the  collection  be  purulent,  and 
show  a  disposition  to  point,  an  opening  for  the 
escape  of  the  fluid  should  be  made  at  the  point 
which  nature  indicates,  but,  in  cases  of  excessive 
effusion,  any  broad  intercostal  space,  between 
the  sixth  and  eighth  ribs  on  the  right,  or  be- 
tween   the  seventh  and  ninth  on   the  left,  might 


INFLAMMATORY    EFFUSIONS    IN    CAVITY.  281 

be  the  point  selected.  The  instrument,  usually 
a  trocar  and  canula,  should  be  introduced  at 
right  angles  to  the  chest  and  near  the  upper 
edge  of  the  rib,  toward  its  angle,  in  a  line 
continuous  with  the  posterior  border  of  the  arm- 
pit. As  this  puncture  corresponds  with  the 
lowest  portion  of  the  cavity,  the  chest  can  be 
perfectly  drained  through  it. 

In  all  gunshot  injuries  of  the  chest,  the  serious 
complication  is  injury  to  the  lungs  or  heart, 
and  it  is  often  difficult  to  detect  at  first  such 
lesions.  Notwithstanding  the  many  infallible 
signs  laid  down  by  authors,  military  surgeons  of 
experience  inform  us  that  no  one  symptom  is 
sufficient  for  making  a  diagnosis.  When  the 
heart  is  injured,  although  instantaneous  death 
does  not  takes  place  as  a  general  rule,  the 
wounded  man  lives  but  a  short  period.  The 
pericardium  soon  becomes  filled  with  blood;  the 
action  of  the  heart  is  mechanically  impeded, 
and,  sooner  or  later,  depending  upon  the  size 
of  the  wound  and  the  facility  for  letting  out 
blood,  it  ceases  its  pulsation.  Reports  of  cases 
are  not  very  rare  in  which  small,  oblique  incised 
wounds  of  the  heart  have  been  recovered  from; 
and  even  gunshot  wounds  of  this  organ,  perfo- 
rating its  cavities,  have  escaped  with  life.  When 
24 


282  SYMPTOMS    OF   LUNG   WOUNDS. 

the  pericardium  is  perforated,  and  the  heart  not 
injured,  a  successful  result  might  be  obtained  by 
a  judicious  course  of  antiphlogistic  treatment, 
which  will  keep  down  inflammation,  with  its  ef- 
fusions of  lymph   and  serum. 

The  lung  often  escapes  injury  when,  from  the 
position  of  the  wounds  of  entrance  and  of  exit, 
with  the  certainty  of  the  cavity  being  transfix- 
ed, the  natural  belief  would  lead  to  a  perfora- 
tion of  the  lung.  A  straight  line  between  the 
wounds  passes  apparently  through  the  substance 
of  the  lung,  but  the  ball  in  perforating  the 
rib  had  been  deflected  from  its  straight  course, 
had  followed,  perhaps,  the  inner  curve  of  the 
chest,  and,  meeting  with  some  resistance,  had 
forced  its  way  through  the  chest,  either  appear- 
ing under  the  tough,  elastic  skin,  or  escaping 
without  touching  the  contained  organs. 

The  lung  may,  on  the  other  hand,  be  se- 
verely injured  when  no  perforating  Avound  ex- 
ists. A  blow  by  a  spent  ball,  or  a  fragment 
of  shell,  may  make  a  very  superficial  wound  or 
bruise  in  the  skin,  and  yet  may  shatter  one  or 
more  ribs,  driving  the  spicula?  into  the  lung, 
lacerating  to  a  greater  or  less  extent  its  sub- 
stance. Even  without  fracture  of  the  ribs,  the 
concussion   or  blow   may  have   been   sufficiently 


SYMPTOMS   OF   LUNG    WOUNDS.  283 

great  to  have  caused  irreparable  injury  to  the 
lung.  The  severity  of  the  symptoms  will  de- 
pend upon  the  depth  of  the  injury  in  the  lung. 
The  deeper  the  lung  is  perforated,  the  larger 
are  the  blood-vessels  implicated  and  the  more 
excessive  and  rapid  the  hemorrhage.  It  is  on 
account  of  this  loss  that  the  most  conspicuous 
symptoms  arise,  viz :  hemorrhage,  collapse  and 
suffocation. 

The  patient  may  be  at  once  suffocated  by  a 
large  quantity  of  blood  filling  up  the  thorax,  and 
preventing  the  ingress  of  air  into  the  lungs. 
Usually  blood  passes  from  both  mouth  and 
wound ;  that  from  the  mouth  is  frothy  and  florid, 
and  is  brought,  up  by  a  short,  tickling,  harass- 
ing cough.  The  size  of  the  dark-colored  stream, 
pouring  from  the  wound,  depends  upon  the  po- 
sition of  the  orifice.  Where  the  orifice  is  sit-* 
uated  low  upon  the  chest,  and  is  large  and  direct, 
the  effusion  into  the  cavity  escapes  freely — the 
symptoms  of  collapse  may  soon  appear,  but 
suffocation  is  prevented;  whilst  from  an  injury 
in  the  upper  portion  of  the  chest,  particularly 
if  small  and  oblique,  the  thorax  may  fill  with 
blood,  and  suffocation  becomes  imminent,  with 
out  much  external  loss.  The  danger  from 
hemorrhage   is   greatest    during   the   first  twelve 


284  SYMPTOMS   OF    LUNG    WOUNDS. 

hours,  and  is  pretty  well  over  by  the  second 
day.  It  may,  however,  continue  for  eight  or  ten 
days,  gradually  diminishing  in  quantity.  With 
the  flow  of  blood  from  the  wound,  air  often 
escapes,  and  the  two  symptoms  are  considered 
unequivocal  proof  that  the  lungs  have  been 
injured,  although  their  absence  do  not  prove  the 
contrary. 

The  mere  loss  of  blood  from  the  lung  is  no 
certain  indication  that  the  organ  has  been  injured, 
as  bloody  expectoration  is  a  common  symptom 
of  blows  upon  the  chest,  and  may  accompany  the 
most  trivial  injury.  Eraser,  in  his  recent  work 
on  gunshot  wounds  of  the  chest,  places  a  less 
value  on  haemoptysis  than  do  other  military  sur- 
geons. Guthrie  considers  it  a  proof  of  lung 
wound,  so  does  Baudens,  McLeod,  Stromyer, 
Ballingall  and  others.  Fraser's  experience  in  the 
Crimea,  gives,  in  nine  fatal  cases  in  which 
the  lungs  were  wounded,  but  one  instance  of 
haemoptysis,  and,  in  seven  fatal  cases  in  which 
the  lungs  were  not  injured,  two  had  a  spitting 
of  blood.  In  twelve  cases  of  recovery,  three  had 
haemoptysis.  He,  therefore,  infers  that  spitting 
of  blood  is  a  very  deceptive  diagnostic  sign  of 
lung  Avound.  When  it  is  rapidly  brought  up  by 
mouthfuls  it  becomes  an  important  symptom. 


SYMPTOMS    OF    LUNG   WOUNDS.  285 

The  discharge  from  the  wound  is  sometimes 
occasioned  by  injury  to  the  intercostal  vessel,  but 
this  is  so  rarely  the  case  that  McLeod  states  that 
he  neither  saw  nor  heard  of  an  instance  during 
the  Crimean  war. 

The  most  distressing  symptom  is  dyspnoea, 
which  may  appear  soon  after  the  injury  has  been 
received,  or,  perhaps,  not  until  some  days  have 
intervened;  in  certain  cases  of  undoubted  lung 
injury  it  may  not  have  been  present  at  any  time. 
This  symptom  is  sometimes  very  intense,  from 
moral  or  other  causes,  when  the  lung  is  not 
wounded,  and  it  may  be  but  slightly  marked,  or 
even  altogether  absent,  when  the  lung  is  seriously 
implicated.  This  difficulty  in  breathing  depends  in 
some  instances  upon  the  direct  pressure  and  con- 
densation of  the  lung  by  air  or  by  fluids.  When 
the  chest  has  been  opened  by  a  ball,  the  lung  does 
not  collapse  as  is  generally  supposed,  but,  if  the 
opening  is  sufficiently  large,  can  be  seen  moving  to 
and  fro  against  the  thoracic  walls  simultaneously 
with  respiration ;  and,  as  a  proof  of  the  continued 
action  of  the  lung,  and  its  inflation  with  air,  it  is 
sometimes  found  protruding  from  the  orifice, 
forming  a  hernia  of  the  organ.  Even  when  the 
lung  has  been  completely  perforated,  it  does  not 
necessarily  collapse,  but  as  blood  escapes  into  the 


286  SYMPTOMS   OF   LUNG   WOUNDS. 

pleural  cavity,  the  lung  may  be  driven  back  and 
condensed  against  the  vertebral  column,  with  the 
accompanying  symptoms  of  dyspnoea.  From  in- 
jury to  the  lung  and  continued  escape  of  air  into 
the  pleural  sac,  we  sometimes  find  similar  diffi- 
culties in  respiration  induced. 

Emphysema  is  a  symptom  of  injury  to  the  lung 
upon  which  much  importance  has  been  placed. 
It  can  occur  under  any  circumstance  by  which  air 
is  admitted  into  the  pleural  cavity,  where,  being 
compressed  by  the  action  of  the  lung  and  walls 
of  the  chest,  it  is  forced  out  through  the  wound; 
but  if  a  ready  exit  is  not  offered  for  its  escape,  or 
should  any  obstacle  exist  in  the  form,  size,  or 
direction  of  the  wound,  it  is  forced  into  the  cel- 
lular tissue.  Owing  to  the  free  communication 
in  the  interstices  of  areolar  tissues,  it  diffuses 
itself  widely  and  rapidly.  Should  a  perforated 
wound  from  ball  or  other  weapon  allow  air  to 
enter  the  pleural  cavity,  whether  the  lung  be 
injured  or  not,  emphysema  might  appear.  It  is 
not  so  common  after  gunshot  wounds,  as  a  free 
exit  is  offered  to  the  contents  of  the  cavity.  It  is 
a  much  more  common  accompaniment  of  oblique 
punctured  wounds  by  sword  point  or  bayonet, 
and  also  in  cases  of  fractured  ribs,  when  sharp 
spicule  of  bone  have  abraided  the  surface  of  the 


SYMPTOMS   OF   LUNG    WOUNDS.  287 

lung  and  allowed  air  to  escape  from  the  air  tubes 
into  the  cavity:  as  it  is  found  either  with  or 
without  lung  injury,  it  cannot  be  of  much  value 
in  diagnosis.  The  injured  lung,  in  gunshot 
wounds,  does  not  often  permit  air  to  escape  for 
any  length  of  time  from  its  wounded  surface,  as 
an  immediate  extravasation  of  blood  into  the 
bruised  tissue  closes  up  the  air  tubes  and  shuts 
oft"  communication  with  the  cavity. 

Another  symptom  of  great  value  is  collapse, 
depending  upon  loss  of  blood.  It  is  well  known 
that  all  the  blood  of  the  body  must  continually 
pass  through  the  lungs,  and  should  the  vessels 
composing  the  parenchyma  of  this  organ  be  ex- 
tensively opened,  the  loss  in  even  a  short  period 
must  be  excessive.  It  is  not  surprising,  therefore, 
that  the  patient  should  soon  become  cold,  pale, 
and  faint — with  feeble,  small  and  irregular  pulse, 
and  with  rapid  tendency  to  syncope.  This  is  na- 
ture's effort  to  check  further  loss;  and  although 
sometimes  successful,  often  gives  but  temporary 
security.  The  surgeon  tries  to  induce  this  con- 
dition for  a  similar  purpose. 

From  consideration  of  the  above  symptoms  we 
are  induced  to  believe  that  no  one  symptom  is 
pathognomonic  of  injury  to  the  lung,  but  it  is 
rather  from  a  combination  of  phenomena  that  any 


288  SYMPTOMS    OF   LUNG   WOUNDS. 

certainty  in  diagnosis  is  attained.  The  imme- 
diate danger  and  intensity  of  the  symptoms  will 
depend  upon  the  depth  of  penetration.  Where 
the  chest  is  only  superficially  wounded,  although 
the  force  of  the  blow  may  be  sufficient  to  produce 
an  amount  of  shock  of  shorter  or  longer  duration, 
and  blood  may  be  expectorated  from  the  concus- 
sion of  the  lungs,  the  symptoms  will  be  trivial. 
The  pain  of  the  bruised  tissues  will  pass  oft'  in 
a  few  days,  and  with  it  all  the  accompanying 
symptoms.  When  the  chest  has  been  opened 
without  injury  to  the  lung,  heart,  or  intercostal 
vessels,  the  symptoms  are  also  trivial,  and  unless 
inflammation  of  the  pleura  and  subsequent  effu- 
sions of  serum  or  pus  should  ensue,  the  case 
will  equally  require  but  little  treatment.  When 
the  lung  is  implicated,  and  especially  when  se- 
verely wounded,  other  symptoms  are  more  or  less 
conspicuously  present.  Soon  after  the  reception 
of  a  severe  wound,  blood  pours  from  the  injured 
vessels  and  escapes  both  into  the  air  tubes  and 
into  the  pleural  cavity. 

From  the  air  vessels  it  is  brought  up  and 
expectorated,  in  greater  or  less  quantity  as 
haemoptysis,  whilst  it  flows  from  the  external 
wound  in  the  side.  If  both  openings  in  lung 
and  chest  be    free,   the   blood  escaping  is  min- 


TREATMENT    OF    LUNG    WOUNDS.  289 

gled  with  air  when  the  patient  coughs.  With 
the  loss  of  blood,  the  surface  becomes  cold  and 
bedewed  with  a  cold  perspiration;  the  pulse  is 
weak  and  tremulous,  becoming  more  and  more 
enfeebled  until  syncope  comes  on,  which  tempo- 
rarily checks  the  excessive  bleeding.  Should  the 
orifice  in  the  side  offer  an  imperfect  escape  to  the 
blood,  it  collects  in  the  pleural  cavity,  rapidly 
encroaches  upon  the  lung,  which  is  forced  back 
against  the  spinal  column,  and  by  compressing 
the  opposite  side  of  the  chest  through  the  medias- 
tinum, threatens  suffocation.  The  eyes  protrude, 
nostrils  expand  to  their  utmost,  the  arms  are 
thrown  about  in  every  direction,  and  frightful 
struggles  for  breath  appear  in  every  feature; 
these  are  the  cases  which,  if  not  immediately 
relieved,  will  in  a  few  moments  terminate  fatally 
by  suffocation. 

The  field  surgeon,  in  transporting  those  wounded 
in  the  chest,  will  give  the  most  careful  attention 
to  the  severely  wounded.  The  simple  cases,  re- 
quiring no  immediate  attendance,  will  be  sent  on 
to  the  field  infirmary.  Although  the  wound  has 
evidently  transfixed  the  chest,  if  no  urgent  symp- 
toms exist,  the  case  is  also  carefully  conveyed  to 
the  infirmary,  or  even  directly  on  to  the  general 
hospital;  but  should  the  distressing  symptoms 
25 


290  TREATMENT    OF   LUNG   WOUNDS. 

above  mentioned  follow  soon  after  the  injury  has 
been  received,  then  the  life  of  the  patient  is  in 
the  hands  of  the  ambulance  surgeon,  and  should 
he  ignore  or  neglect  the  case,  the  soldier  may  not 
reach  the  infirmary  alive.  Notwithstanding  the 
hemorrhage,  open  a  large  vein  and  draw  away 
blood,  if  possible,  to  syncope.  The  safety  of  the 
patient  depends  upon  this  being  obtained ;  as  in 
the  interval,  when  the  heart's  action  is  at  its 
minimum,  but  little  blood  will  be  driven  to  the 
lungs,  and  a  disposition  to  the  formation  of  a  clot 
may  plug  up  the  bleeding  vessels.  The  dyspnoea, 
and  not  the  pulse,  will  be  the  indication  for 
bleeding  in  lung  wounds.  The  patient  is  not 
detained  on  the  field  to  see  the  effects  of  the 
venesection,  but,  with  his  vein  open,  is  sent  on  to 
the  field  infirmary,  accompanied  by  the  surgeon 
himself,  or  by  an  intelligent  assistant.  As  soon 
as  he  faints,  the  surgeon  at  the  field  infirmary 
removes  the  rough  field  dressing,  examines  the 
wound  with  the  finger,  and,  if  not  sufficiently 
large  to  permit  a  thorough  search  for  foreign 
bodies,  w^here  such  are  suspected,  he  dilates  it 
with  a  probe-pointed  bistoury. 

In  perforating  chest  wounds,  unless  urgent 
symptoms  of  dyspnoea  are  present,  the  general 
treatment    is    the    expectant    plan.      The   wound 


TREATMENT    OF    LUNG    WOUNDS.  291 

having  been  carefully  closed  with  diachylon, 
the  patient  lies  on  the  wounded  side,  so  as  to 
throw  the  lung  against  the  orifice,  hoping  that 
it  may  adhere  to  the  chest  at  that  point,  and  so 
close  the  cavity ;  he  also  finds  this  the  most 
comfortable  position.  He  is  kept  quiet,  in  a 
dark  room;  all  excitants  are  avoided,  rigid  diet 
is  instituted;  veratrum  viride,  or  digitalis,  is 
given  to  control  the  action  of  the  heart;  opium 
is  freely  administered  to  quiet  the  constant  hack- 
ing, trickling  cough,  and  iced  cloths  or  bladders 
are  applied  to  the  chest.  "With  such  treatment 
and  careful  watching,  seeing  the  patient,  if  pos- 
sible, every  hour,  we  await  the  development  of 
symptoms.  The  accurate  closure  of  the  wound 
excludes  the  admission  of  air,  and,  to  a  certain 
extent,  prevents  emphysema,  and  also  the  rapid 
decomposition  of  the  escaped  fluids  in  the  cavity. 
If  it  be  a  shot  wound,  with  a  single  orifice, 
and  the  clothing  be  found  perforated,  the  wound 
should  be  examined  for  foreign  bodies.  If  found, 
extract  them  ;  if  not  detected,  then  close  the 
wound  carefully  with  a  strip  of  diachylon,  and 
apply  the  water  or  ice  dressing.  The  search  for 
foreign  bodies  must  always  be  made  with  the 
finger,  and  should  never  be  protracted.  Should 
nothing   be   found   after   a   moderate,    intelligent 


292  TREATMENT    0F~LTJNG    WOUNDS. 

search,  close  the  wound,  and  await  developments. 
This  examination  should  be  made  before  reac- 
tion comes  on.  Should  we  not  see  the  patient 
until  he  is  feverish,  all  examinations  must  be  ab- 
solutely forbidden  for  at  least  eight  days,  until 
the  reaction  has  subsided  and  suppuration  well 
established.  It  is  well  known  that  balls,  etc., 
even  pieces  of  clothing,  have  been  found  encyst- 
ed in  the  lungs  years  after  they  had  been  de- 
posited ;  and,  in  some  instances,  these  articles 
have  been  expectorated  during  a  severe  spell  of 
coughing,  after  long  intervals.  Although  always 
desirable  that  these  be  removed,  a  prolonged 
search  may  entail  such  an  amount  of  injury  as 
to  destroy  all  hope  of  saving  the  patient,  when 
the  presence  of  the  foreign  body  would  not  have 
been  necessarily  incompatible  with  life  or  even 
health.  Besides,  when  suppuration  is  well  estab- 
lished, we  have  a  second  and  much  better  oppor- 
tunity for  a  careful  examination,  without  much 
fear  of  doing  injury. 

Should  the  gradual  accumulation  of  blood  in 
the  cavity  of  the  chest  cause  dyspnoea,  the  orifice 
may  require  opening,  to  allow  the  fluid  to  escape 
and  relieve  the  pressure  upon  the  lung.  In 
drawing  off  the  contents  of  the  chest,  if  syncope 
threatens,  we  close  the  opening,  and  await  anoth- 


TREATMENT    OF    LUNO    WOUNDS.  293 

er   opportunity.      The   collection    is   retained    in 
certain    cases,   when    no    dyspnoea   exists,  for  the 
purpose  of  retarding,  and  finally  controlling  the 
bleeding,  by  pressure  upon  the  lung  and  its  in- 
jured   blood-vessels.     After    the    third  or  fourth 
day,  the  tendency  to  hemorrhage  having   ceased, 
and   the   wound    having   already   commenced   to 
suppurate,  the    adhesive   plaster  is  removed,  and 
the    effusion  is   allowed  to    escape.      If   air    has 
been  admitted  into  the  cavity,  the  exuded  blood 
has  decomposed  and,  mingled  with  serum  and  pus, 
makes    a    copious  and   very    offensive    discharge 
for  the  first  few  days.      Gradually  the  escaping 
fluid    loses   its    dark    color    and    offensive   smell, 
and    assumes    the    appearance    of   healthy    pus. 
Formerly  much  care  was  taken  to  favor  the  flow 
of  fluids   from   the   chest,   and   dilatation   of   the 
wound  was  the  recognized  rule  ;  now,  the  oppo- 
site treatment  is   the   one  urged   to  exclude  air, 
and  if  possible,  retard  decomposition,  as  this  de- 
terioration of  the  effused  fluids  is  more  injurious 
to  the  system  than   the   advantages  obtained  by 
their    ready    escape.      From    this    time    onward, 
simple  water  dressing- will  be  the  only  local  treat- 
ment   required    for   the    wound.      If  the    orifice 
from    a   punctured   wound   has  healed,  with    es- 
caped   blood    remaining    within    the    chest,    the 


294  TREATMENT    OF    LUNG    WOUNDS. 

collection,  if  small,  should  be  ignored,  as  it 
will  gradually  be  absorbed  ;  but  if  the  extrava- 
sation be  extensive,  particularly  if  air  had  pre- 
viously entered  the  cavity,  it  must  be  withdrawn 
through  a  puncture  made  at  the  most  dependant 
portion  of  the  chest.  This  operation,  unless  call- 
ed for  by  urgent  or  distressing  symptoms,  should 
never  be  hastily  performed,  but  should,  on  the 
contrary,  be   delayed  as   long  as  possible. 

During  the  treatment  of  perforating  wounds  of 
the  chest,  dyspnoea,  whenever  urgent,  should 
always  be  removed  by  the  lancet,  the  venesection 
to  be  repeated  as  frequently  as  called  for  by 
threatened  suffocation,  unless  this  symptom  be 
clearly  traced  to  pent-up  fluid,  when  opening  the 
wound  or  enlarging  it,  to  permit  a  ready  escape, 
will  remove  the  oppression  of  breathing.  Prompt 
and  repeated  venesection  will  also  be  required  to 
control  hemorrhage,  which  is  a  common  cause  of 
death  in  such  injuries,  and  will  alone  diminish  the 
•number  of  victims  of  chest  wounds.  In  collapse, 
we  have  already  recognized  a  valued  aid  for 
checking  hemorrhage,  and  its  remediable  advan- 
tages should  be  appreciated.  As  a  symptom,  it 
must  be  carefully  watched,  and  should  it  threaten 
to  stop  the  action  of  the  heart,  external  stim- 
ulation   must   be   freely   used,    but    the    internal 


TREATMENT    OP    LUNG    WOUNDS.  295 

stimuli  must  be  administered  only  in  small 
quantity  and  with  great  caution.  When  the 
immediate  dangers  have  passed,  the  next  in  or- 
der is  inflammation  of  the  lung  and  pleura. 
Neither  of  these  conditions  differ  in  any  very 
material  respect  from  the  idiopathic  varieties  of 
the  disease.  The  traumatic  pneumonia  is  some- 
times circumscribed  to  narrow  limits,  and  its 
cause  may,  to  a  certain  extent,  modify  the  gen- 
eral symptoms.  As  the  cause  of  pleuritis  is  a 
direct  injury  to  the  membrane,  and,  in  the  ma- 
jority of  instances,  as  air  has  been  admitted 
within  the  cavity,  the  effusions  which  accom- 
pany the  inflammation  soon  become  purulent, 
and  in  time  false  membranes  of  considerable 
thickness  line  the  inner  surface  of  the  ribs.  The 
treatment  for  either  pneumonia  or  pleurisy, 
when  occurring  from  a  gunshot  wound,  does  not 
differ  from  the  treatment  of  the  disease  from  any 
other  cause.  McLeod's  experience  is  in  favor  of 
early,  active,  and  repeated  bleedings,  with  cool 
drink  and  abstemious  diet,  recognizing,  at  the 
same  time,  however,  that  many  excellent  recov- 
ries  have  been  made  without  recourse  to  the 
lancet.  Guthrie  uses  the  lancet,  wThich  he  desig- 
nates the  first  and  most  essential  remedy,  and 
which  he   says   should    be    resorted   to  in   every 


296  TREATMENT    OP   LUNG   WOUNDS. 

case.  The  venesection,  which  he  repeats  when- 
ever the  inflammatory  symptoms  show  an  increase, 
is  vigorously  followed  by  large  doses  of  tartar 
emetic  in  pneumonia,  and  calomel  in  pleurisy, 
the  object  being  to  affect  the  gums  as  soon  as 
possible.  This  is  the  treatment  of  the  old  school, 
which  recent  experience  does  not  uphold.  Guth- 
rie states  "that  in  the  Crimea  bloodletting  had 
not  been  so  favorably  viewed,  nor  found  so  ser- 
viceable, nor  so  necessary."  Fraser,  from  Cri- 
mean experience,  states  that  in  the  prevention 
and  reduction  of  inflammatory  action  in  perfora- 
ting wounds  of  the  chest,  venesection  is  not 
demanded.  It  should  only  be  used  when  the 
pulse  is  full,  strong,  and  labored — a  condition 
not  often  met  with.  "When  the  heart  and  pulse 
are  both  weak,  a  common  condition  after  severe 
wounds,  the  abstraction  of  blood  will  occasion  a 
complete  prostration  of  strength,  and  may  be 
fatal. 

There  is  no  reason  for  changing  the  plan  of 
treatment,  already  discussed  in  detail,  for  com- 
bating inflammation  following  gunshot  wounds, 
and  which  is  equally  applicable  to  chest  wounds. 
Even  when  the  lung  is  inflamed  we  would  prefer 
the  mild,  expectant  and  antiphlogistic  treatment 
to  the  spoliative.     Absolute    rest,   cooling  bever- 


TREATMENT    OF    LUNG    WOUNDS.  '±{.H 

ages,  moderate  nourishment,  avoiding  over-stimu- 
lation, with  small  doses  of  tart,  emetic,  veratrum 
or  digitalis,  with  the  liberal  use  of  opium,  and 
attention  to  the  intestinal  secretions,  will  be  re- 
quired in  all  cases,  and  in  many  will  compose 
.the  entire  treatment. 

A  certain  degree  of  pleuritis  is  expected  and 
desired  in  penetrating  lung  wounds,  to  establish 
adhesions  between  the  injured  lung  and  thoracic 
wall,  which  will  at  once  isolate  the  injured  portion 
and  prevent  inflammatory  sequela?.  As  gunshot 
wrounds  do  not  close  rapidly  but  usually  suppu- 
rate, permitting  the  free  access  of  air  within  the 
thorax,  the  suppuration  will  be  profuse  and  long- 
continued.  We  must  remember  this  in  the  treat- 
ment, and  not  use  depressing  agents.  When  the 
pleuritis  is  excessive  and  general,  both  false  mem- 
branes and  the  rapid  accumulation  of  fluid  are  to 
be  anticipated.  If  the  external  wound  is  still 
open,  the  position  of  the  body,  which  is  very 
important,  will  allow  the  ready  escape  of  the 
effusion,  which  is,  at  first,  serous,  but  soon  be- 
comes purulent.  Position  and  constitutional  sup- 
port will  form  the  basis  of  treatment.  If  the 
pus  could  have  a  constant  outlet  for  escape,  and 
accumulation  within  the  cavity  could  be  pre- 
vented, the  false  membranes  would  tie  the  lung 


29S  TREATMENT    OF    LUNG    WOUNDS. 

to  the  thoracic  wall  at  a  much  earlier  period, 
and,  by  obliterating  the  pleural  cavity,  prevent 
further  discharge.  Should  the  wound  be  in  the 
upper  portion  of  the  chest,  it  wrould  hasten  the 
cure  to  establish  a  counter-opening  from  the 
most  dependant  portion  of  the  cavity,  from  which 
the  drain  would  never  be  interrupted. 

The  chapter  on  the  treatment  of  suppurating 
wTounds  lays  down  general  lawrs  for  counteract- 
ing the  injurious  influences  of  long-continued 
suppuration.  Penetrating  wounds  of  the  thorax 
occasionally  remain  fistulous  for  an  almost  indefi- 
nite period,  which  is  caused  by  a  failure  of  gen- 
eral adhesion  between  the  costal  and  pulmonary 
pleurae.  A  kind  of  pouch  is  found,  lined  by  a 
false  membrane,  from  which  a  purulent  lymph 
is  continually  secreted.  After  empyema,  the 
chest  contracts,  the  walls  sink  in,  the  diaphragm 
rises  high  on  the  affected  side,  the  spine  becomes 
contorted,  air  enters  indifferently  into  the  lung, 
little  or  no  respiratory  movements  are  seen  in 
the  chest,  and  a  portion  of  the  respiratory  appa- 
ratus is  rendered  useless  to  the  economy.  Usu- 
ally, the  long  train  of  symptoms  terminate  fatally 
in  phthisis.  Very  few  cases  of  injury  to  the 
lung,  from  gunshot  wounds,  are  ever  restored 
to  health. 


TREATMENT    OP    LUNG    WOUNDS.  299 

In  cases  of  fractured  ribs,  from  gunshot  injuries, 
the  bone  is  usually  spiculated,  and  some  of  the 
fragments  may  accompany  the  ball  in  its  onward 
course.  Upon  examination  with  the  finger — 
executed  with  great  caution  from  the  fear  of 
pushing  the  fragments  into  the  chest  and  con- 
verting a  simple  wound  into  a  perforating 
wound,  always  a  serious  accident — these  irregu- 
lar fragments,  if  detected,  should  be  removed, 
and,  if  necessary,  the  outer  wound  should  be 
enlarged  to  facilitate  this  important  step.  The 
danger  is  not  so  much  from  the  breaking  of 
the  bone,  but  from  the  displaced,  sharp  frag- 
ments, which  may  seriously  injure  the  pleura? 
and  lung.  When  removed,  and  the  sharp  edges 
of  the  rib,  which  turn  in  toward  the  cavity, 
are  excised,  the  wound  should  be  closed  with  a 
wide,  adhesive  strap,  and  cold  water  dressings 
applied.  If  no  symptoms  indicate  injury  to  the 
lung,  a  broad  band  may  surround  the  chest,  to 
control  the  thoracic  movements  and  allay  the 
pain  ;  but,  should  any  oppression  in  the  breath- 
ing show  itself,  the  bandage  cannot  be  applied,  as 
it  will  increase  the  suffocative  feelings.  Where 
the  spicule  are  not  displaced,  a  broad  adhesive 
strap  is  the  only  local  apparatus  required.  Ne- 
crosis of  the  rib  very   commonly  follows  a  gun- 


300  TREATMENT    OF    LUNG    WOUNDS. 

shot  fracture,  and  may  require  a  subsequent  re- 
section for  its  removal. 

When  an  intercostal  artery  is  divided,  the  bleed- 
ing point  will  be  discovered  by  drawing  out  the 
lips  of  the  wound  with  a  tenaculum,  when  the 
vessel  should  be  secured.  All  military  surgeons 
agree  that  this  operation  is  more  frequently 
spoken  of  than  performed.  Many  of  extensive 
experience  have  never  seen  a  case. 

When  foreign  bodies,  as  balls,  pieces  of  bone, 
cloth,  wadding,  etc.,  are  driven  into  the  pleural 
cavity  they  produce  fatal  results,  by  inflamma- 
tion and  exhausting  discharges,  unless  removed. 
A  loose  ball  can  be  sometimes  felt  by  the  patient, 
and  its  movements  often  detected  by  the  stethe- 
scope.  Through  an  opening,  made  at  the  most 
dependant  portion  -of  the  chest,  the  foreign  body 
can  be  removed  successfully. 


CHAPTER  X. 

Wounds  of  abdomen — Flesh  wounds — Never  probe 
perforating  wounds  of  the  abdomen,  and,  especially, 
never  attempt  to  search  for  foreign  bodies  which 
have  passed  beyond  the  abdominal  walls — Sew  up 
intestinal  wounds — Dilate  wound,  in  abdomen  when 
necessary  to  relieve  strangulation  and  facilitate  re- 
duction—  Where  the  larger  viscera  are  injured,  re- 
covery is  rare — Avoid  using  purgatives  when  the 
intestine  is  wounded — Peritonitis  a  common  cause 
of  mortality — Where  the  intestine  is  much  crushed, 
leave  it  out  of  the  wound,  or  excise  the  crushed 
portion  and,  close  the  intestinal  wound,  by  sutures — 
In  wounds  of  the  bladder,  continued  use  of  catheter 
essential. 

Sir  Charles  Bell  has  remarked  that,  although 
abdominal  wounds  hore  a  fair  relative  proportion 
to  other  wounds,  immediately  after  a  battle,  a 
few  days  sufficed  to  remove  them — so  that,  by 
the  end  of  the  first  week,  there  was  scarcely  one 
to    be  seen.     As  a  rule,    all  who  have   received 


302  PERFORATING    WOUND. 

wounds  of  the  large  abdominal  viscera  die — the 
exception,  of  restoration  to  health,  being  rarely 
met  with.  Like  wounds  of  the  chest,  where  the 
abdominal  walls  are  not  perforated,  but  the  en- 
tire track  of  the  ball  lies  in  the  thickness  of  the 
muscles, "the  wound  is  simply  a  flesh  wound  and 
should  be  treated  accordingly.  The  track  of  the 
ball  is  not  always  in  a  straight  course,,  as  the 
muscles,  or  their  tendinous  portions,  when  in 
action,  offer  sufficient  resistance  to  turn  the  ball. 
The  fascia  transversalis  is  said  to  show  a  similar 
resistance  to  oblique  shot. 

A  perforating  wound  of  the  abdomen  is  equally 
dangerous  as  those  of  the  chest,  from  the  fear  of 
peritonitis,  which  is  apt  to  supervene.  If  the 
perforation  be  made  by  a  sword  or  bayonet,  or 
if  there  be  any  prospect  of  healing  by  the  first 
intention,  the  wound  should  be  accurately  closed 
by  adhesive  straps  or  by  sutures.  In  sewing  up 
an  abdominal  wound,  many  recommend  that  the 
needle  should  not  pass  deeper  than  the  super- 
ficial cellular  tissue,  giving  as  a  reason  that 
when  the  muscles  are  included  in  the  sutures, 
they  sometimes  draw  themselves  out  of  the  noose 
by  their  contraction,  whilst,  if  the  peritoneum  be 
also  included,  peritonitis  is  much  more  likely  to 
occur.      Although   this  may   hold   good   for   the 


PERFORATING    WOUND.  303 

peritoneum,  I  can  see  no  reason  why  attempts 
should  not  be  made  to  cause  union  in  the  muscles, 
and,  therefore,  avoiding  the  peritoneum,  I  would 
include  all  the  tissues,  even  to  the  transversalis 
fascia,  in  the  suture.  When  this  is  done,  the 
cicatrix  will  be  firmer,  and  there  will  be  less 
probability  of  secondary  hernia — a  very  common 
accident  after  injury  to  the  abdominal  wTalls. 

In  probing  abdominal  wounds,  the  only  object 
to  be  sought  by  the  examination  is  whether  the 
w.ound  has  perforated  or  not.  From  the  direction 
of  the  track  this  can  nearly  always  be  determined. 
As  in  any  other  gunshot  wound,  the  use  of  the 
silver  probe  is  very  dangerous,  as  it  may  convert 
a  simple  into  a  perforating  wround;  whilst  with 
the  finger,  or  a  gum  bougie,  the  course  of  the 
wound,  should  it  be  a  flesh  wound,  can  be  traced, 
and  also  the  existence  of  foreign  bodies  detected. 
Should  we  find  that  the  opening  transfixes  the 
abdominal  wall,  our  examination  should  go  no 
further — it  is  a  dangerous  amusement  to  satisfy 
curiosity  at  the  expense  of  such  irreparable  mis- 
chief as  may  destroy  the  life  of  the  patient. 

If  the  wound  be  a  large  one,  as  when  made  by 
a  sabre-bayonet,  fragment  of  shell,  or  Minnie 
ball,  a  portion  of  the  abdominal  contents  may 
protrude  from  the  wound.     When  the  ambulance 


304  PERFORATING    WOUND. 

surgeon  finds  such  a  case  on  the  field,  his  first 
duty  will  be  to  examine  the  protrusion.  If  it  be 
a  portion  of  small  intestine  and  be  not  injured,  he 
cleanses  it  of  dirt  and  all  other  extraneous  sub- 
stances, by  pouring  water  upon  it,  and  carefully 
returning  it  within  the  abdomen,  closes  the 
wound  by  sutures,  if  it  be  an  incised  wound ; 
or  a  broad  strip  of  diachylon  plaster,  if  a  gun- 
shot wound.  He  then  administers  a  dose  of  mor- 
phine, and  sees  that  the  wounded  man  is  properly 
transported  to  the  field  infirmary.  To  facilitate 
the  return  of  the  protrusion,  whether  it  be  intes- 
tinal or  omental,  the  patient  is  placed  upon  his 
back  with  the  thighs  drawn  up,  and  the  ab- 
dominal muscles  relaxed,  when  the  ambulance 
surgeon  makes  steady  pressure  upon  the  protru- 
sion in  the  direction  of  the  wound.  The  bowel 
must  be  handled  very  carefully — no  force  should 
be  used,  or  so  much  injury  might  be  inflicted  as 
to  cause  the  rupture,  sloughing  or  inflammation  of 
the  protruding  organ.  The  better  plan  would  be 
to  encircle  the  protrusion  by  the  fingers  clustered 
together  as  a  funnel  or  cone,  which  will  diminish 
the  bulk  at  the  opening  in  the  abdomen,  and 
facilitate  its  return.  If  it  be  found  that  the 
mass  is  so  constricted  by  the  small  size  of  the 
orifice,   that   the    return     within    the    abdominal 


PERFORATING    WOUND.  305 

cavity  is  impossible  without  inflicting  injury 
upon  the  bowel,  the  intestine  should  be  drawn 
to  one  side,  and,  using  great  caution,  the  wound 
should  he  enlarged  upward  for  a  quarter  or 
half  an  inch.  As  the  constriction  is  rarely  in 
the  peritoneal  wound  but  usually  in  the  muscles 
and  fascia,  the  incision,  if  possible,  should  not 
include  the  peritoneum.  Cutting  upon  a  grooved 
director,  or  using  a  probe-pointed  bistoury,  will 
diminish  the  dangers  of  wounding  important 
parts  wuthin  whilst  enlarging  the  wound.  The 
return  of  the  bowel  should  always  be  effected 
b}T  the  ambulance  surgeon  before  the  case  is 
transported  to  the  field  infirmary,  inasmuch  as 
the  crowding  of  the  wounded  at  the  infirmary 
may  be  such  that  several  hours  might  elapse 
between  the  receipt  of  injury  and  the  hospital 
examination — quite  long  enough  to  cause  stran- 
gulation of  the  intestine,  and  either  necessitate 
inflammation  or  mortification  of  the  protrusion, 
usually  a  fatal  complication  in  abdominal  wounds. 
The  early  return  of  the  protruding  intestine 
makes  the  case  one  for  simple  and  successful 
treatment.  Be  satisfied  that  the  intestine  has 
been  returned  wTithin  the  abdominal  cavity,  and 
not  forced  under  the  sheaths  of  the  abdominal 
26 


306  INTESTINAL    INJURY. 

muscles,  where  it  would  strangulate  and  rapidly 
destroy  life. 

Should  the  case  not  be  seen  until  several  hours 
had  elapsed,  the  intestine  should  he  equally  re- 
turned whether  it  he  congested  or  inflamed;  hut 
when  gangrenous,  which  is  recognized  by  its 
greenish  ash  color,  loss  of  polish,  its  flaccid 
condition,  with  already  a  disposition  to  separa- 
tion in  its  various  coats,  it  should  remain  without 
the  wound,  and  be  laid  open  so  as  to  allow  its 
fecal  contents  to  be  evacuated.  Adhesions  rapidly 
form,  uniting  the  protruded  intestine  to  the  peri- 
toneum at  the  inner  orifice  of  the  wound.  This 
shuts  off'  all  connection  with  the  peritoneal 
cavity,  and  prevents  extravasation  of  fecal  mat- 
ter within  it.  If  the  bowel  be  returned  in  a 
mortified  condition,  the  contents  of  the  bowel 
would  be  discharged  into  the  peritoneal  cavity, 
and  fatal  peritonitis  would  be  excited. 

Should  the  intestine  be  injured,  it  is  left  in 
situ,  covered  with  a  wet  or  oiled  cloth,  until  the 
wounded  soldier  reaches  the  field  infirmary,  when 
it  is  closed  with  one,  two,  or  more  points  of  inter- 
rupted suture,  according  to  the  size  of  the  open- 
ing— a  stitch  being  placed  for  every  one-sixth 
of  an  inch  of  intestinal  wound.  The  ends  of 
the   suture   are    cut   off*  close    to    the    knot,    and 


INTESTINAL    INJURY.  307 

the  whole  is  returned  into  the  abdomen  with 
care.  A  fine  cambric  needle  will  be  the  best 
instrument  for  sewing  up  intestinal  wounds,  as 
the  small  puncture  and  fine  thread  produce 
scarcely  any  irritation.  In  passing  the  sutures, 
do  not  include  the  lining  mucus  membrane  in 
the  noose,  for  if  this  be  allowed  to  pout  between 
the  lips  of  the  intestinal  wound  it  might  inter- 
fere with  rapid  healing ;  the  serous  or  perito- 
neal layers  should  be  brought  in  contact,  when 
union  rapidly  follows. 

If  a  large  dose  of  opium  had  been  admin- 
istered on  the  battle  field,  or  as  soon  as  the 
patient  had  arrived  at  the  infirmary  whilst  await- 
ing his  turn  to  be  dressed,  the  peristaltic  action 
of  the  bowels  would  have  been  suspended,  and 
the  wounded  portion  of  the  bowel,  which  should 
always  be  the  last  portion  returned,  when  the 
hernia  is  extensive,  remains  within  the  abdomi- 
nal cavity,  in  immediate  contact  with  the  wound, 
and  to  this  point  it  soon  becomes  attached 
through  adhesive  inflammation.  Should  the  su- 
tures give  way,  or  the  bowel  slough  from  the 
injury  which  it  had  received,  its  contents,  instead 
of  being  thrown  into  the  peritoneal  cavity  where 
it  would  produce  fatal  inflammation,  on  account 
of  the  adhesions  of  the    bowel    near  au  external 


308  INTESTINAL   INJURY. 

outlet,  will  escape  externally,  which  diminishes 
materially  the  risk  run  by  the  patient.  The 
threads  used  in  closing  the  opening  in  the  intes- 
tine either  escape  through  the  bowel  by  stool, 
or  are  discharged  through  the  abdominal  wound. 

When  examining  the  external  wound  when  no 
protrusion  exist,  should  we  find  an  escape  of  fecal 
matter — which  proves  that  the  bowel  has  been 
perforated — the  abdominal  wound  must  be  en- 
larged, and  the  wound  in  the  intestine  closed  by 
suture.  This  is  the  only  expedient  for  saving 
life;  for  if  the  contents  of  the  bowel  are  allowed 
to  escape  into  the  peritoneal  cavity,  a  fatal  issue 
must  be  expected.  The  dilatation  of  the  wound 
diminishes  the  risks. 

Should  the  intestine  be  extensively  injured 
beyond  the  possibility  of  saving  it,  rather  than 
return  a  portion  of  bowel  within  the  abdomen 
to  mortify  and  destroy  the  patient,  it  should  be 
left  hanging  out  of  the  wound.  All  of  the  sound 
portion  of  the  protrusion  having  been  returned, 
the  crushed  portion  is  enveloped  in  a  wet  or 
oiled  cloth.  The  peritoneal  coat  of  the  bowel 
will  form  adhesions  to  the  peritoneal  edge  of  the 
abdominal  wound,  the  outer  portion  sloughs,  and 
an  artificial  anus  gives  constant  escape  to  the  fecal 
contents.     In  time,  this  artificial  outlet  gradually 


INTESTINAL   INJURY.  309 

closes  by  a  spontaneous  effort  of  nature,  the  fteces 
seeking  their  normal  passage,   or  an  operation  at 
some   subsequent   period   removes  the  deformity. 
In  examining  the  archives  of  surgery,  we  find 
cases   in   which   portions    of  the  intestines   have 
been   cut  off,  the  cylinder  of  the  bowel  reunited 
by    sutures,    and    excellent    recoveries    obtained. 
These  experiments  have  been   tried   successfully 
upon  animals,  and  instances  are  met  with  where 
the  human  subject  has   been   saved  by  a  similar 
operation.     I  have  recently  had  under  my  care  a 
lunatic,    who,     some     months     since,     attempted 
suicide   by   opening   his    abdomen,    drawing   out 
his  bowels,  and  cutting  oft*  two  feet  of  intestine. 
Dr.  Gaston,  of  Columbia,  S.  C,  who  had  the  case 
under  charge,  brought  the  two  ends  of  the  intes- 
tine  together,    and    securing    them    by    carefully 
arranged     sutures,    returned     them     within     the 
cavity.     The   patient  made    a    perfect    recovery. 
This  accident,   which   terminated   so   successfully 
for  the  lunatic,  suggests  an  operation  for  a  crushed 
intestine,  which  may  offer  better  prospects  than 
leaving  the  bowel  to  slough  and  form  an  artificial 
anus : — remove    the    injured   portion,    secure   the 
bleeding  vessels,  and  reclose  the  intestine  by  su- 
tures,  treating   the    case   as  if  an  incised  wound 
of  the  bowel  had  alone  existed. 


310  INTESTINAL   INJURY. 

In  all  perforating  wounds  of  the  abdomen,  as 
we  cannot  tell,  in  the  absence  of  symptoms, 
whether  the  intestines  have  been  injured  or  not, 
there  are  two  fundamental  rules  of  treatment 
never  to  be  forgotten,  and  which  are  required 
in    every  instance. 

1.  Give  opium  freely  and  frequently,  with  a 
double  object,  viz:  of  controlling  the  peristaltic 
action,  which  alone  can  prevent  extravasation  of 
the  contents  into  the  peritoneal  cavity,  and  for 
its  antiphlogistic  effect,  to  equalize  the  circula- 
tion, allay  pain,  suspend  nervous  irritability,  and 
prevent  inflammation. 

2.  Avoid  the  use  of  purgatives. 

With  the  majority  of  physicians  who  have  had 
but  little  experience  in  the  treatment  of  abdomi- 
nal wounds,  the  first  impulse  is  to  see  the  bowels 
emptied,  and  hence  the  fatal  purgative  is  eagerly 
administered.  An  evacuation  apparently  reassures 
them  that  all  is  right;  when  on  the  contrary,  all 
is  very  wrong,  as  the  march  of  the  case  will  soon 
show  them.  This  is  a  fatal  error,  which  the 
utmost  after-care  cannot  remedy.  For  three  or 
four  days  at  least  after  the  receipt  of  injury,  in 
which  the  intestines  are  known  or  are  supposed 
to  be  wounded,  absolute  rest,  the  most  abstemi- 
ous diet,  and  the  liberal  use  of  opium  (one  grain 


INTESTINAL    INJURY.  311 

of  gum  opium,  or  its  equivalent  in  laudanum, 
every  five  hours)  in  connection  with  cold  water 
or  iced  dressing,  will  compose  the  entire  treat- 
ment. If  the  patient  feels  uneasy,  an  enema  will 
relieve  the  large  intestines  and  add  much  to  his 
comfort.  By  the  fourth  day,  the  wound  in  the 
intestines  will  have  closed  by  lymphy  effusion, 
and  the  dangers  will,  to  a  certain  degree,  have 
subsided.  If  required,  a  dose  of  Epsom  salts, 
citrate  of  magnesia,  or  castor  oil,  may  now  be 
given,  although  it  would  be  better  to  wait  one  or 
two  days  louger,  when  the  risks  of  reopening  or 
disturbing  the  wound  would  be  but  slight. 

If  peritoneal  inflammation  be  excited  with  fe- 
brile reaction,  with  pain  greatly  increased  by 
pressure  over  the  abdomen,  more  particularly 
in  the  neighborhood  of  the  wound,  with  tympa- 
nitis, vomiting,  hiccup,  small,  quick  pulse,  and 
anxiety  of  countenance,  the  fears  are  -that  lymph 
and  sero-purulent  matter  will  be  rapidly  thrown 
out,  gluing  coils  of  intestines  together,  and 
filling  the  cavity  with  fluid.  To  check  this 
rapidly  fatal  disorganization,  leeches  or  cups 
should  be  applied  to  the  abdomen,  to  be  fol- 
lowed by  ice  bladders,  which  are  now  preferred, 
or  by  hot  narcotic  or  turpentine  stupes,  or  by 
blisters,  whilst   opium  should   be  given  in  large 


312  INTESTINAL    INJURY. 

doses  and  at  short  intervals.  If  the  patient  he 
young  and  plethoric,  and  the  inflammatory  symp- 
toms are  early  recognized,  the  lancet  might  be 
used;  hut  usually  in  military  surgery  this  reme- 
dy is  badly  borne.  Calomel  was  formerly  used 
with  the  opium,  and  was  considered  the  main 
dependence,  but  is  now  being  generally  dis- 
carded, as  all  advantages  gained  are  accredited 
to  the  opium. 

Sometimes,  in  a  few  hours,  usually  at  the  end 
of  the  second  or  third  day,  collapse,  with  a  cold, 
sweating  skin,  and  feeble,  irregular  pulse,  shows 
the  ravages  which  the  system  has  experienced 
from  the  peritoneal  inflammation,  and  marks 
rapidly-approaching  dissolution.  It  is  rare  that 
the  liberal  use  of  brandy  with  carbonate  of  am- 
monia, external  warmth  and  synapisms  rescue 
the  patient  at  this  advanced  stage;  although,  if 
given  when  debility  commences  to  show  itself, 
they  may  support  the  patient,  and  be  the  means 
of  saving  life.  When  the  swelling  of  the  ab- 
domen, and  the  dull  sound  which  percussion 
elicits,  shows  extensive  effusion,  the  abdominal 
wound  should  be  reopened,  and,  by  placing  the 
patient  in  a  proper  position,  the  effusion  be  allow- 
ed to  escape.  It  is  a  desperate  operation,  but 
lias   been   known  to  save   a  few  cases,  which,  if 


INTESTINAL   INJURY.  313 

left  alone,  would  have  certainly  perished  as  those 
do  upon  whom  this  operation  is  not  performed. 

In  gunshot  wounds  of  the  abdomen,  if  the 
missile  has  perforated,  it  would  be  madness  to 
probe  the  abdominal  cavity.  We  must  imagine 
the  worse,  give  the  patient  the  benefit  of  these 
doubts,  and  by  extreme  care  hope  to  counteract 
the  baneful  influences  which  foreign  bodies,  when 
remaining  in  the  abdominal  cavity,  always  exer- 
cise. The  ball  may  have  traversed  the  cavity  and 
embedded  itself  in  the  fleshy  walls  without  having 
injured  any  organ  of  importance  in  its  course; 
the  absence  of  serious  symptoms,  as  the  case  pro- 
gresses, can  alone  inform  us  on  this  head.  From 
the  physiological  eifects  we  might,  at  times,  trace 
the  resting  place  of  the  ball.  When  paralysis  of 
the  lower  limbs  follows  an  abdominal  gunshot 
wound,  we  might  infer  the  burying  of  the  ball  in 
the  vertebral  column,  or  an  injury  to  the  nerves 
of  the  extremity  as  they  emerge  from  the  spine, 
etc. 

Should  the  abdominal  wound  bleed  profusely, 
the  source  of  blood  may  be  from  within  the 
cavity  from  injured  viscera,  or  may  be  caused  by 
division  of  the  epigastric  artery  in  the  abdomi- 
nal walls.  If  the  latter,  dilatation  of  the  wound 
will  expose  it,  and  the  vessel  should  be  ligated. 
27 


314        HEMORRHAGE    FROM    ABDOMINAL    INJURIES. 

When  from  the  former  source  but  little  can  be 
done,  venesection  to  syncope  might  check  the 
flow,  and  the  formation  of  a  clot  may  plug  up 
the  injured  vessel.  Some  surgeons,  knowing 
the  desperate  condition  brought  on  by  internal 
hemorrhage,  recommend  dilating  the  wound,  and 
should  it  be  found  that  hemorrhage  comes  from 
one  of  the  mesenteric  vessels,  the  artery  should 
be  ligated.  The  position  of  the  external  wound 
will  assist  us  in  forming  a  diagnosis  as  to  the 
probable  source  of  the  hemorrhage.  Cases  of 
recovery  are  recorded  where  the  wound  was 
dilated,  and  the  bleeding  vessel  in  the  omentum 
sought  and   secured. 

"Where  some  of  the  large  viscera  or  blood- 
vessels are  injured  in  perforating  abdominal 
wounds,  the  symptoms  are  much  more  marked 
than  in  intestinal  wounds;  hemorrhage  at  once 
takes  place  to  a  serious  and  often  fatal  extent. 
Such  wounded  are  often  found  dead  upon  the  bat- 
tle field;  or  should  they  be  alive,  they  are  pale  and 
cold,  with  anxious  countenances  and  intense  long- 
ing for  water.  This  insatiable  thirst  is  not  pecu- 
liar to  visceral  wound  or  to  nervous  shock,  but 
is  an  indication  of  serious  hemorrhage.  If  the 
wound  be  extensive  they  never  rally  from  this  col- 
lapse.    In  other  cases,  the  shock  may  permit  the 


HEMORRHAGE    FROM    ABDOMINAL    INJURIES.        315 

clogging  of  injured  blood-vessels,  and  stop  inter- 
nal bleeding.  Should  life  be  prolonged  until 
reaction  takes  place,  the  violent  inflammation 
which  is  lit  up,  either  from  direct  injury  to  the 
peritoneum,  or  from  the  quantity  of  blood  in  the 
cavity,  usually  carries  off  the  patient  after  a  pe- 
riod of  intense  suffering.  On  account  of  the 
hemorrhage  and  subsequent  inflammation  which 
accompany  these  injuries,  all  wounds  of  the  larger 
abdominal  viscera  are  considered  nearly  neces- 
sarily mortal,  as  the  exceptional  cures  are  very 
rare.  When  the  external  orifice  is  small,  the 
position  and  direction  of  the  wound  will  lead 
us  to  suspect  the  special  injury,  and,  in  connec- 
tion with  persistent  vomiting,  the  ejection  of 
blood  by  the  mouth,  by  stool,  or  vrlth  the  urine  ; 
the  escape  of  special  secretions,  as  bile,  urine, 
or  fa?ces  by  the  wound  ;  and  the  peculiar  pain 
or  sensations  experienced  by  the  patient,  will  be 
our  chief  indications  in  determining  the  part  in- 
jured. 

The  treatment  of  these  serious  wounds,  which 
on  the  whole  is  so  unsatisfactory,  is  similar  to 
that  required  for  perforating  wounds  of  the  chest, 
with  injury  to  the  lungs.  If  seen  soon'  after  the 
accident,  before  much  blood  has  been  extrava- 
sated,  and  if  nervous  shock  is  not  present,   the 


316  INJURY   TO.  BLADDER. 

patient  should  be  bled  nearly  to  syncope  for  its 
anti-hemorrhagic  effect,  and  then  opium  inter- 
nally, and  cold  locally,  become  the  basis  of  treat- 
ment. 

In  loounds  of  the  kidney,  frequent  micturition 
with  bloody  urine  marks  the  injury;  whilst  in 
injuries  to  the  bladder,  bloody  urine,  or  rather,  the 
passage  of  clots  as  well  as  pure  blood  through 
the  penis,  is  the  diagnostic  sign:  should  urine 
escape  from  the  wound,  it  is  equally  pathogno- 
monic. In  addition  to  the  course  already  laid 
down  for  internal  abdominal  injuries,  the  intro- 
duction of  a  large  gum  catheter  into  the  bladder 
through  the  penis,  through  which  urine  is  allowed 
to  drain  away  as  fast  as  it  is  secreted,  will  prevent 
urinous  infiltration,  which  is  one  of  the  most  fatal 
complications  connected  with  a  wounded  bladder. 
The  catheter  should  be  introduced  on  the  field 
of  battle,  and  should  be  worn  continuously  for 
four  or  five  days  until  adhesive  inflammation  has 
closed  the  torn  cellular  tissue,  and  shut  up  the 
avenues  into  which  the  urine  would  have  escaped. 
The  catheter  will  also  be  required  when  the 
sloughs  are  separating,  as  swelling  of  the  parte 
often  obstructs  the  ready  flow  of  urine.  The  gum 
catheter  may  even  be  kept  in  from  the  com- 
mencement of  the  treatment  until  the  wound  is 


CRUSHING    OF    ABDOMINAL    VISCERA.  317 

well  advanced  in  healing,  unless  it  excites  much 
irritation,  when  it  may  be  temporarily  with- 
drawn. This  precaution  will  prevent  many  cases 
of  urinous  infiltration   and  save  many  lives. 

When  the  neck  of  the  bladder,  or  the  prostatic 
part  of  the  urethra  has  been  divided,  if  the 
catheter  cannot  be  introduced,  a  free  incision 
should  be  made  through  the  perineum  for  the 
evacuation  of  urine  and  the  discharges  from  the 
wound. 

Injury  to  the  large  intestines  are  not  so  serious 
as  perforations  of  the  small.  As  the  large  bowel 
is  bound  down  in  the  greater  part  of  its  course, 
extravasations  of  their  contents  do  not  necessarily 
take  place  into  the  peritoneal  cavity;  and  although 
fecal  matter  escapes  externally  from  the  wound, 
and  high  inflammation,  with  profuse  suppuration, 
usually  follows,  many  of  the  wounded  eventually 
do  well. 

Cases  not  unusually  occur  on  the  battle  field 
in  which  the  abdominal  contents  might  be  severe- 
ly crushed  without  apparent  external  injury.  It 
is  the  toughness  and  elasticity  of  the  skin  which 
gives  rise  to  the  exploded  theory  of  the  wind  of 
a  ball  destroying  life;  and  such  cases  as  those  we 
are  now  considering  were  formerly  brought  for- 
ward as  instances  of  the  fatal  effects  of  the  vacuum 


318  THE    EFFECT    OF    SPENT    BALLS. 

following  the  wake  of  a  cannon  ball.  Observa- 
tion has  shown  that  a  knapsack  might  be  torn 
from  the  back,  a  hat  struck  from  the  head,  an 
epaulet  from  the  shoulder,  or  a  pipe  from  the 
mouth,  without  leaving  a  trace  of  injury,  whilst, 
on  the  other  hand,  viscera  might  be  reduced  to 
a  jelly,  or  bones  crushed,  without  visible  bruising 
of  the  skin.  It  is  the  ball  itself,  and  not  the 
wind,  which  produces  these  disorganizations. 
From  the  blow  of  a  spent  cannon  ball  or  frag- 
ment of  shell,  the  liver  might  be  lacerated, 
intestines  torn,  blood-vessels  opened,  spleen  fis- 
sured, or  kidney  ruptured,  without  an  external 
wound.  Severe  shock  and  collapse  mark  the 
extent  of  injury  received;  and  should  the  patient 
rally  from  this  condition,  which  is  rare,  violent 
inflammation  will  soon  destroy  life.  Although 
we  follow  vigorously  the  treatment  laid  down 
above,  we  very  seldom  have  the  satisfaction  of 
saving  a  patient. 

The  amount  of  destruction  effected  by  a  spent 
ball  is  often  surprising.  The  uninitiated  on  the 
battle  field  will  attempt  to  stop,  with  the  foot,  a 
cannon  ball  rolling  on  the  ground,  and  which  is 
just  about  exhausting  its  force,  perhaps  with  only 
momentum  sufficient  to  carry  it  one  or  two  feet 
further,  }7et  it  crushes  the  limb  put  out  to  oppose 


THE    EFFECT   OF    SPENT    BALLS.  319 

it.  Baudens,  in  warning  persons  to  avoid  cannon 
balls,  however  slowly  they  may  be  rolling  on  the 
ground,  mentions  the  case  of  a  grenadier  of  the 
guard,  sleeping  on  his  side  on  the  ground,  who 
was  instantly  killed  by  a  spent  cannon  ball,  the 
blow  from  which  luxated  the  vertebral  column. 
The  ball  came  with  so  little  momentum  that  it 
rolled  itself  up  in  the  hood  of  the  soldier's  over- 
coat, where  it  was  found.  It  was  just  about  to 
stop  when  it  struck.  One  or  two  feet  further,  and 
its  entire  force  would  have  been  exhausted. 


CHAPTER    XI. 

Injuries  of  the  extremities;  compound  fractures; 
difference  of  treatment  in  the  upper  and  lower 
limbs;  importance  of  an  early  examination  and 
adoption  of  a  course  of  treatment  within  twenty- 
four  hours  after  the  receipt  of  accident — Compound 
fractures  of  the  arm  from  shot  wounds,  when  not 
implicating  joints,  do  not  require  amputation;  should 
the  blood-vessels  and  nerves  be  crushed  with  the  bone, 
then  amputation  necessary —  When  gunshot  fractures 
implicate  joints,  resection  or  amputation  is  the  only 
means  of  saving  life;  how  resections  are  to  be  per- 
formed; special  resections  of  shoulder,  elbow,  wrist — 
Resections  and,  amputations  of  the  inferior  extremity 
— Primary  and  consecutive  amputation;  when,  and 
under  what  circumstances  should  amputations  be 
performed — Modes  of  operating  and  of  dressing 
stumps — Chloroform  in  all  serious  operations. 

As  the  major  portion  of  the  injuries  of  the 
extremities  are  merely  flesh  wounds,  these  will 
not  require  to  be  again  noticed.     Those  which  we 


INJURIES    OF    THE    EXTREMITIES.  321 

will  now  consider  are  such  as  involve  the  bones, 
joints,  or  important  vessels,  and  which  may  call 
for  special  treatment.  It  is  in  this  department 
that  conservative  surgery  has  made  the  greatest 
advances,  and  has  accomplished  so  much  iu 
diminishing  mortality  and  mutilation.  ISTot  that 
amputations  will  ever  be  abolished,  for  many 
lives  can  be  saved  in  no  other  way  than  by  the 
sacrifice  of  limbs;  but  conservative  surgery  has 
shown  that  the  constant  flourish  of  the  ampu- 
tating knife  is  not  the  way  to  obtain  the  greatest 
number  of  surgical  victories  in  times  of  war. 
Amputations  must,  however,  ever  remain  a  surgi- 
cal necessity;  and  he  who  removes  crushed  limbs 
with  the  greatest  skill,  and  saves  the  patient  by 
successful  after-treatment,  will  ever  deserve  the 
high  position  which  humanity  and  philanthropy 
will  bestow  upon  him. 

In  gunshot  wounds  of  the  extremities,  we  find 
a  much  greater  vitality  and  resistance  to  injuries 
in  the  upper  than  in  the  lower  limbs,  which 
would  modify  the  treatment  of  similar  injuries 
located  in  these  two  portions  of  the  body.  This 
depends  upon  the  greater  vascularity  and  freer 
anastomosis  in  the  arm  than  in  the  leg.  In  the 
more  liberal  supply  of  blood-vessels  and  nerves, 
we  find  the  source  of  safety  which  enables  us  to 


322  COMPOUND    FRACTURES. 

save  an  arm,  when,  for   a   similar   injury,   a   leg 
would  be  generally  condemned. 

The  most  common  accidents  of  the  extremities 
which  give  surgeons  the  greatest  annoyance  and 
require  the  most  careful  diagnosis,  prognosis  and 
treatment,  are  compound  fractures.  These  have 
always  been  a  numerous  and  important  class  in 
military  surgery,  but  have  become  doubly  so  in 
modern  warfare,  from  the  substitution  of  coni- 
cal shot  for  the  round  musket  ball.  This  projec- 
tile never  impinges  upon  a  bone  without  leaving 
frightful  traces  of  devastation.  Such  a  conical 
ball  very  rarely  remains  embedded,  but  acting  on 
the  principle  of  a  wedge,  it  splits  and  comminutes 
the  bone,  driving  the  loose  spiculse  in  every 
direction,  and  even  detaching  some  of  them 
from  the  body  to  impale  neighboring  soldiers. 
Crimean  surgeons,  who  have  had  many  opportu- 
nities of  observing  injuries,  from  every  description 
of  missile,  in  referring  to  the  conical  ball,  speak 
of  their  effects  as  so  dissimilar  to  those  of  round 
balls,  as  almost  to  justify  a  classification  of  injur- 
ies founded  upon  the  kind  of  ball  giving  rise  to 
them.  They  state  that  the  longitudinal  splitting 
of  the  bone  is  so  dexterously  and  extensively 
accomplished  by  the  conical  ball,  that  while 
only  a  small  opening  leads  to  the  seat  of  fracture, 


COMPOUND    FRACTURES.  323 

the  whole  shaft  may  be  rent  from  end  to  end. 
Fortunate  is  it  that  this  extensive  splitting  or 
Assuring  of  the  long  bones  does  not  exteDd  into 
the  joints,  or  the  cases  for  operation  would  be 
much  more  numerous  than  they  now  are.  The 
epiphysis  of  the  bone  appears  not  to  transmit  the 
force  of  cleavage,  as  the  injury  most  frequently 
stops  at  the  junction  of  the  head  of  the  bone 
with  its  shaft.  The  successful  treatment  of  such 
wounds  requires  much  judgment  and  experience, 
with  a  thorough  knowledge  of  those  agencies 
antagonistic  to  the  healing  of  wounds,  and  which 
belong  to  military  surgery. 

"When  a  bone  is  crushed  by  a  ball,  the  patient 
is  conveyed  very  carefully  to  the  field  infirmary; 
or,  if  it  can  be  done  without  delay,  to  the  general 
hospital,  where  the  treatment  commences  On 
the  field,  the  ambulance  surgeon  can  do  nothing 
but  administer  a  dose  of  morphine,  and  secure 
the  limb  to  a  rough  splint  to  facilitate  transpor- 
tation. For  a  fractured  clavicle,  scapula  or  hu- 
merus, the  arm  is  bandaged  to  the  chest,  which, 
on  the  battle  field,  answers  the  purpose  of  a 
temporary  splint;  for  a  crushing  of  the  forearm 
or  hand,  the  arm  is  laid  upon  a  broad  splint,  and 
slung  from  the  neck.  If  the  splint  is  not  at  hand, 
the  slins;  made  of  a  handkerchief  must   answer 


324       SHOULD  THE  LIMB  BE  AMPUTATED  ? 

until  the  wounded  man  can  be  better  attended 
to;  it  being  understood  that  a  wet  or  greased 
cloth  is  always  put  over  the  wound  for  its  pro- 
tection   during   the  transportation. 

When  he  arrives  at  the  hospital,  the  limb  is 
carefully  examined.  The  external  wound  may 
give  no  indication  of  the  extent  of  internal  injury. 
When  the  finger  is  introduced  and  the  wound 
carefully  explored,  the  degree  of  crushing  will  be 
ascertained,  and  the  question  at  once  proposes 
itself,  what  course  shall  we  pursue?  Shall  we 
attempt  to  save  the  limb;  or  does  its  condition, 
with  the  want  of  proper  facilities  for  its  successful 
treatment,  necessitate  its  condemnation?  If  we 
have  had  experience  in  the  care  of  gunshot  frac- 
tures, we  should,  with  Sir  Charles  Bell,  contem- 
plate what  will  be  the  condition  of  the  parts  in 
twelve  hours,  in  six  days,  or  in  three  months. 
"  In  twelve  hours  the  inflammation,  pain  and  ten- 
sion of  the  whole  limb,  the  inflamed  countenance, 
the  brilliant  eye,  the  sleepless  and  restless  condi- 
tion, declare  the  impression  the  injury  is  making 
on  the  limb  and  on  the  constitutional  powers.  In 
six  days,  the  limb,  from  the  groin  to  the  toe,  or 
from  the  shoulder  to  the  linger,  is  swollen  to  half 
the  size  of  the  bod}';  a  violent  phlegmonous 
inflammation  pervades  the  whole;  serous  effusion 


SHOULD  THE  LIMB  BE  AMPUTATED  ?      325 

has  taken  place  in  the  whole  limh,  and  abscesses 
are  forming  in  the  great  beds  of  cellular  texture 
throughout  the  whole  extent  of  the  extremity. 
In  three  months,  if  the  patient  has  labored 
through  the  agony,  the  bones  are  carious;  the 
abscesses  are  interminable  sinuses;  the  limb  is 
undermined  and  everywhere  unsound,  and  the 
constitutional  strength  ebbs  to  the  lowest  degree." 
All  these  conditions  must  be  rapidly  considered, 
and  with  them  the  more  immediate  dangers  of 
mortification,  and  the  remote  dangers  of  erysipe- 
las, pyaemia  and  hectic,  and  the  questionable 
utility  of  the  limb,  when,  after  several  months 
of  continued  trials,  the  wound  has  been  healed. 
Business  presses  and  time  is  valuable.  "Within 
twenty-four  hours,  or  before  reaction  ensues, 
whilst  the  patient  has  his  sensibilities  depressed 
by  the  shock,  our  conclusions  must  be  made  and 
acted  upon;  success  of  treatment  depends  upon 
prompt  action  —  the  delay  of  a  few  days  has 
destroyed  thousands  of  wounded.  Should  ampu- 
tation be  required,  there  is  no  period  in  the  pro- 
gress of  the  case  so  favorable  for  the  performance 
of  this  operation  as  the  first  four  and  twenty 
hours.  Should  an  injudicious  attempt  be  made 
to  save  the  limb,  amputation  cannot  be  resorted 
to    with    any  hope    of   success  until  suppurative 


826       SHOULD  THE  LIMB  BE  AMPUTATED? 

action  has  been  well  established.  Should  ery- 
sipelas attack  the  wound,  an  amputation  is  im- 
practicable; and  when  gangrene  has  supervened, 
during  the  stage  of  reactionary  excitement,  we 
are  driven  to  an  operation  under  the  most  un- 
favorable circumstances. 

There  are  many  compound  fractures  upon 
which  judgment  can  be  immediately  passed:  with 
some,  there  is  every  probability  that  the  limb 
can  be  saved;  whilst  there  are  others  in  which 
the  limb  is  condemned  at  a  glance — our  prog- 
nosis being  based  upon  the  following  circum- 
stances : 

As  the  upper  extremity  can  sustain  a  much 
more  serious  injury  than  the  lower,  we  may  lay 
it  down  as  a  rule  that  a  simple  compound  frac- 
ture of  any  of  the  long  bones  of  the  arm,  when 
not  complicated  3vith  excessive  crushing  of  the 
soft  parts,  can,  and  should  be  saved.  An  arm  is 
rarely  to  be  amputated  except  from  the  effects  of 
a  cannon  shot,  which,  beside  crushing  the  bones, 
makes  frightful  lacerations  of  the  soft  tissues, 
tearing  away  muscles,  nerves,  and  blood-vessels, 
and  often  amputating  completely  the  limb — the 
surgeon  being  required  only  to  give  a  better  form 
to  the  stump. 

For  a  gunshot  wound  from  a  musket  or  Minnie 


REMOVE    SPICULE.  327 

ball,  which  has  fractured  the  bones  of  the  arm 
without  implicating  a  joint,  the  following  is  the 
course  to  be  pursued.  At  the  field  infirmary 
the  wound  is  carefully  probed  with  the  finger, 
and  its  spiculated  condition  noted.  All  loose 
fragments  are  to  be  removed  at  this  first  ex- 
amination before  reaction  ensues,  for  it  will  be 
very  injurious  to  the  wound,  as  well  as  exces- 
sively painful  to  the  soldier,  to  continue  such 
examinations  from  day  to  day.  The  first  exami- 
nation should  always  be  effectual.  The  patient 
is  then  suffering  from  shock,  with  sensibility 
temporarily  blunted,  and  is  therefore  in  the  best 
condition  to  be  operated  upon.  To  render  this 
first  examination  complete,  should  the  shock  have 
passed  off  and  the  patient  complain  of  much 
pain,  it  would  be  better  to  give  him  large  doses 
of  opium,  or  administer  chloroform,  rather  than 
desist  from  this  important  portion  of  the  treat- 
ment. Should  we  omit  to  bring  away  all  spiculse, 
the  further  removal  should  not  be  attempted 
during  the  stage  of  excitement  and  febrile  reac- 
tion which  will  come  on  after  twenty-four  hours, 
and  which  will  run  its  course  in  six  or  eight 
days.  When  this  subsides,  then  and  not  before, 
we  make  the  second  examination,  and  by  the 
use  of  instruments,  remove  any  loose  fragments 


328  REMOVE    SPICULE. 

which  we  now  detect.  We  will  simply  men- 
tion, in  this  connection,  that  as  there  is  not  the 
slightest  probability;  or  even  possibility,  of  the 
wound  closing  by  the  first  intention,  the  inser- 
tion of  tents  and  pieces  of  lint  is  a  relic  of  bar- 
barous surgery,  which  cannot  be  too  severely 
condemned  as  useless,  injurious,  and  very  painful. 
Modern  surgery  recommends  that  all  spicuhe, 
whether  detached  or  not,  should  be  removed;  but 
this  practice  is  not  upheld  by  surgeons  gene- 
rally. Experience  and  observation  has,  in  some 
instances  shown,  that  although  the  larger  frag- 
ments may  be  detached  from  the  shaft  of  the 
bone,  they  may  still  be  adherent  to  the  peri- 
osteum, which  will  effect  a  reunion  and  con- 
solidation. On  the  other  hand,  experience  and 
observation  have  shown  that,  from  the  force 
with  which  conical  shot  strike  a  bone,  the  spi- 
cule, which  are  very  numerous,  are  driven  in 
every  direction,  but  mostly  toward  the  opening 
of  escape  of  the  ball.  These  sharp  splinters  can- 
not but  produce  excessive  irritation  in  the  soft 
parts,  and  may,  by  transfixing  vessels,  pricking 
nerves,  or  irritating  muscles,  induce  hemorrhage, 
mortification,  or  tetanus.  No  surgeon  doubts  the 
propriety  of  removing  all  such  on  the  spot,  or 
at   the   earliest  possible   moment.     As  the  open- 


REMOVE    SPICULE.  329 

ing  of  exit,  around  which  the  larger  number  of 
the  fragments  are  found,  may  be  too  contract- 
ed to  admit  of  a  thorough  exploration  of  the 
wound,  it  will  not  increase  the  dangers  but,  on 
the  contrary,  materially  diminish  the  risks  of 
after-trouble,  if  the  wound  of  exit,  in  compound 
fractures  with  crushing  of  the  bone,  be  dilated 
so  as  to  facilitate  the  detection  and  removal  of 
every  spicula.  In  enlarging  this  orifice,  injury 
to  the  important  blood-vessels  and  nerves  will,  of 
course,  be  avoided. 

On  the  subject  of  removing  all  fragments, 
whether  detached  or  not,  there  appears  to  be  a 
diversity  of  opinion,  which  is  based  upon  the 
changes  introduced  into  modern  warfare.  The 
older  surgeons,  who  base  their  treatment  on 
the  effects  of  the  musket  ball,  know  that  often 
the  connection  of  the  fragments  to  the  soft  parts 
and  to  the  periosteum  will  guarantee  a  consolida- 
tion of  the  fragments.  The  rouud  ball  simply 
breaks  the  bone  without  scattering  the  frag- 
ments, and  therefore  their  relations  to  the  sur- 
rounding tissues  will  not  be  so  materially 
changed.  But  notwithstanding  this  impression, 
which  may  or  may  not  be  correct,  what  does 
actual  experience  prove,  when  brought  down  to 
facts  ?  Take  the  experience  given  by  the  inmates 
28 


330  REMOVE    SPICULE. 

of  the  Hotel  des  Invalides,  as  recorded  by  M. 
H'utin,  the  surgeon  of  the  institution.  He  states, 
that  those  spiculse  which  had  been  attached 
to  the  soft  parts,  and  which  were  allowed  to  re- 
main in  the  hope  of  reunion,  although  they  may 
not  give  trouble  at  the  moment,  invariably  end 
by  becoming  sequestra,  and  after  a  long  period 
of  pain  and  suppuration,  demand  removal.  He 
reports  several  hundred  cases  in  which  the  non- 
extracted  fragments,  sooner  or  later,  set  up  an 
eliminative  action,  which  is  always  painful,  often 
dangerous,  and  at  times  fatal.  M.  Hutin  refers 
chiefly  to  the  effects  of  round  or  musket  balls. 
Baudens  gives,  as  his  Crimean  experience,  "that 
whether  adherent  or  not,  it  is  better  to  remove  all 
spiculee,  and  thus  simplify  the  wound.  If  these 
be  retained,  endless  suppuration,  continued  suffer- 
•  ing,  with  exacerbations  of  all  the  symptoms  at  the 
escape  of  each  fragment,  will  gradually  exhaust 
the  vital  forces,  and  entail  its  sequela?  of  maras- 
mus, diarrhoea  and  hectic."  Suppuration  will 
eventually  bring  all  of  the  fragments  to  the  sur- 
face, but  at  what  a  sacrifice! 

McLeod,  after  quoting  the  experience  of  Roux, 
Baudens,  Guthrie,  Hutin,  Dupuytren,  Curling, 
Begin,  and  others,  on  the  dangers  of  allowing 
movable  fragments  to  remain7  and  the  necessity 


REMOVE    SPICULE.  831 

of  extracting  every  piece  which  is  not  extensively 
attached  to  the  soft  parts,  gives  his  experience  as 
decidedly  in  favor  of  the  modern  practice  of  re- 
moving all  movable  spiculce  as  the  best  mode  of 
hastening  a  cure  and  diminishing  mortality,  "as 
the  removal  must  tend  immensely  to  simplify  the 
wound." 

Again,  he  says:  "The  extensive  comminution 
of  the  bone  by  a  conical  ball,  makes  the  indica- 
tions with  regard  to  the  management  of  the 
sequestra  more  evident  than  it  is  commonly  con- 
sidered. I  do  not  think  that  we  paid  sufficient 
attention  to  their  removal  in  the  East.  It  may 
be  true,  as  some  tell  us,  that  in  fractures  with 
the  old  ball,  it  was  desirable  to  meddle  as  little 
as  possible  with  the  fragments;  but  this  is  the 
teaching  of  only  a  few.  However,  to  my  mind, 
the  question  assumes  a  totally  different  light 
when  viewed  by  the  pathological  results  which 
we  had  occasion  to  witness." 

Some  surgeons  go  further,  and  recommend  that 
not  only  should  all  spicule  be  removed,  but  that 
the  sharp,  irregular  ends  of  the  bones  should  be 
sawed  off.  This  suggestion  has  not  met  with  gen- 
eral approval,  and  is  spoken  of  by  Stromyer  and 
Loeffler  as  no  improvement.  Their  experience 
gave  a  larger  mortuary  list  when  this  practice 
was  attempted. 


332  TREATMENT. 

There  is  no  doubt  that  the  removal  of  all  frag- 
ments, in  which  there  is  not  a  strong  probability 
of  reunion  taking  place,  will  expedite  the  cure. 
In    surgery,    whenever    we     are     in    doubt,    we 
should  always  give  the  patient  the  benefit  of  it; 
and  in  the  subject  under  consideration,  knowing 
that  the  removal  of  spicule,  which  might  effect 
consolidation,    can    do    no    harm,    whilst    leaving 
them  in,  should  union  not  be  obtained,  would  be 
followed   by   much   danger,    annoyance,    and  suf- 
fering,  we   give   the   patient   the    benefit    of   the 
doubt,  and  remove  them  at  the  first  examination. 
Feeling  now  secure,  that  we  have  removed  every 
foreign  body,  and  have  left  nothing  in  the  wound 
which    is    likely   to    retard   the    cure,    we    should 
ignore  the  presence  of  the   wound   as   much    as 
possible,  and  treat  the  case  as  one  of  simple  frac- 
ture.    Inflammation  and  suppuration  we  expect; 
the}-  are  the  portion  of  compound  fractures  gen- 
erally,   and    especially   of    those    connected   with 
gunshot  wounds ;  and  remembering  the  long  con- 
tinued  and    profuse    drain   which    will   establish 
itself  in  four  or  five   days,  we  should  be  careful 
how   we   make   use    of  the    active   antiphlogistic 
treatment.      For  the  first   week  or  ten  days,  the 
arm  may  be  stretched  upon  a  pillow,  or  loosely 
secured  to  a  broad,  long  splint,  which  will  support 


PAIN    NOT    NECESSARY    FOR    HEALING.  333 

the  entire  extremity.  "We  confine  the  treatment 
to  cold  water  dressings,  either  as  iced  bladders, 
applied  over  compresses  to  remove  the  injurious 
effects  of  direct  application,  or  as  by  the  process 
of  irrigation — either  of  which  is  better  than  the 
continued  renewal  of  wet  cloths.  The  general 
treatment  during  this  period  of  inflammatory 
excitement,  is  diet,  rest,  epiiet,  and  the  use  of 
mild  diaphoretics,  diuretics,  and  the  liberal  use 
of  opium. 

Pain  we  do  not  consider,  in  any  sense,  neces- 
sary to  the  healing  of  wounds,  and  therefore 
have  always  made  it  a  rule  in  practice  to  reduce 
it  to  its  minimum.  The  complete  annihilation 
of  pain  will  neither  detract  from  the  rapidity  of 
healing,  nor  from  the  gratitude  of  patients.  The 
impropriety  of  free  catharsis,  will  be  at  once 
evident  from  the  movements  made  necessary  by 
their  action.  Bloodletting,  emetics,  and  the  use 
of  mercury  we  absolutely  discard,  as  always  use- 
less and  injurious  in  the  treatment  of  any  stage 
of  compound  fractures.  As  soon  as  the  period 
of  inflammatory  reaction  has  subsided,  we  then 
apply  such  splints  to  the  arm  as  will  secure  quiet 
and  rest  to  the  limb,  whilst  a  free  vent  is  allowed 
in  the  apparatus  for  the  escape  of  discharges  from 
the  wound;  this  opening  also  permits  water  dress- 
ings being  applied  to  the  wound. 


334      TREATMENT  OF  COMPOUND  FRACTURES. 

It  cannot  be  expected  that  an  arm,  after  a 
serious  gunshot  injury  to  the  bones,  will  be  cured 
without  deformity.  The  arm  will  always  be 
shortened,  where  many  spiculse  have  been  re- 
moved. We  acknowledge  this  fact  in  anticipa- 
tion, and  never  attempt,  by  traction  and  counter- 
extension,  to  restore  it  to  its  former  length.  We 
simply  place  the  arm  in  an  easy  position  and 
allow  the  muscles  to  approach  the  broken  ends. 
In  the  treatment  of  ordinary  fractures,  the  main 
object  is  to  prevent  deformity,  and  especially 
shortening  of  the  limb.  As  this  object  is  dis- 
carded in  compound  fractures  of  the  upper  ex- 
tremity, the  treatment  becomes  much  simplified, 
and  the  patient  is  saved  its  greatest  annoyance. 

In  fractures  of  the  arm,  the  pasteboard  splints 
are  to  be  preferred;  whilst  for  the  forearm, 
wooden  splints,  made  of  light  material  and  wider 
than  the  diameter  of  the  arm,  will  make  the  best 
application.  The  tumefaction  bandage  is  not 
now  insisted  on,  and  by  many  surgeons  is  nearly 
altogether  discarded.  In  gunshot  injuries,  where 
we  have  an  open  wound  to  dress  daily,  our 
mechanical  applications  should  be  of  such  a 
character  as  to  permit  of  easy  inspection  and 
also  the  ready  re-adjustment  of  the  apparatus 
when  disarranged  ;  whilst,  at  the  same  time,  the 


TREATMENT    OF    COMPOUND    FRACTURES.  335 

splints  are  kept  secure.  Diachylon  plaster  is 
now  extensively  used  to  secure  splints  to  frac- 
tured limbs:  three  or  four  bands  encircling  the 
limb  will  always  secure  the  supporting  appa- 
ratus, whilst  the  limb  is  freely  open  to  inspection. 
When  the  pasteboard  is  moistened,  it  moulds  itself 
to  the  arm  and  makes  a  very  satisfactory  dressing. 
As  soon  as  the  patient  has  passed  the  reactive 
stage,  he  should  no  longer  be  confined  to  his  bed, 
but  with  his  arm  in  a  sling  may  obtain  sufficient 
exercise  to  keep  his  system  in  good  order.  The 
erect  position  will  have  the  additional  advantage 
of  permitting  the  ready  discharge  of  pus,  and  will 
prevent  the  bagging  of  this  fluid,  and  obviate  the 
necessity  for  the  establishment  of  counter-open- 
ings. In  all  simple  fractures  the  excess  of  callus 
depends  upon  the  degree  of  mobility  between  the 
broken  ends  ;  in  compound  fractures  the  deposit 
for  consolidation  is  usually  very  great,  which  may 
be  explained  by  the  amount  of  irritation  from 
inflammatory  action,  and  also  by  the  difficulty 
of  keeping  the  fragments  without  motion.  For- 
tunately, this  does  not  interfere  with  the  final 
results,  as  false  joints  are  not  more  frequently 
met  with  in  compound  than  in  simple  fractures. 
Experience  shows  us  that  there  is  not  that  neces- 
sity, which  many  practice,  of  frequently  tightening 


336  TREATMENT    OF    COMPOUND    FRACTURES. 

the  apparatus,  to  the  very  great  annoyance  of  the 
patient.  If  the  constitution  be  strong,  a  consid- 
erable degree  of  relaxation  may  be  permitted,  and 
be  found  not  incompatible  with  perfect  consoli- 
dation. In  animals  with  compound  fractures,  we 
see  continual  exemplifications  of  this  fact. 

The  local  and  general  treatment  of  the  wound, 
will,  in  no  respect,  be  modified  on  account  of  the 
fracture.  Water  dressings,  until  cicatrization  is 
completed,  medicated  with  astringents  to  allay 
profuse  discharges,  or  with  antiseptics  to  remove 
fnetor,  or  with  stimuli  to  promote  granulations, 
will  be  the  proper  course,  whilst  the  general 
health  is  watched,  retarded  secretions  promoted, 
and  debility  guarded  against.  If  any  fragments 
of  bone  have  been  left  in,  and  have  become 
necrosed,  the  surgeon  must  assist  nature  in  the 
expulsion  as  soon  as  they  have  become  detached, 
otherwise  they  will  become  surrounded  by  new 
formations,  and  as  sequestra,  incarcerated  in  an 
involucrum,  will  only  be  expelled  after  much  time 
and  trouble.  From  time  to  time,  when  spiculse 
are  suspected,  the  wound  should  be  examined, 
especially  about  the  eighth  or  tenth  day  from  the 
receipt  of  injury,  when  the  stage  of  reaction  has 
subsided  to  such  an  extent  that  the  finger  can 
again  be  introduced.     From  the  passing  off  of  the 


INJURIOUS  CLEANSING.  337 

shock,  all  examination  must  be  absolutely  inter- 
dicted until  the  period  of  reaction  lias  subsided. 
During  the  first  week,  no  one  should  be  per- 
mitted to  probe  the  wound.  As  soon  as  we 
conclude  that  all  fragments  have  been  removed, 
we  desist  from  all  further  probing,  as  it  cannot 
but  be  injurious  to  the  delicate  granulations. 

Cleanliness  is  necessary  to  successful  hospital 
practice  in  the  treatment  of  suppurating  wounds, 
but,  when  excessive,  becomes  a  serious  obstacle 
to  rapid  cicatrization.  It  is  a  common  error  for 
surgeons. to  place  a  wounded  limb  over  a  basin 
of  water,  and  sponge  and  rub  it  as  if  they  were 
cleansing  a  piece  of  porcelain.  I  have  seen  others 
dress  gunshot  wounds  by  the  free  use  of  a  power- 
ful syringe,  with  which  they  poured  a  stream  of 
water  into  the  wound  until  the  granulations 
were  bleached,  and  this  repeated  with  great  reg- 
ularity at  the  morning  and  evening  visit.  It  was 
not  surprising  that  wounds,  treated  with  this 
over-care,  took  a  very  long  time  to  heal.  If  the 
wound  be  gangrenous,  and  the  object  be  to  re- 
move ichorous  decomposing  fluids,  to  diminish  or 
prevent  absorption  and  general  poisoning,  then 
the  syringing  is  desirable ;  but  under  no  other 
conditions  wipe  or  wash  the  granulating  surface 
of  a  wound.  Wipe  around  the  edges  and  remove 
29 


338  WHEN    ARE    AMPUTATIONS    REQUIRED? 

any  secretions  which  might  have  collected  upon 
the  skin,  but  leave  the  pus,  as  the  best  covering 
which  healthy  granulations  can  have.  Under  its 
protection,  the  plasma,  which  is  thrown  out  from 
the  blood-vessels,  will  rapidly  form  tissues ;  but 
rub  or  wash  away  this  covering,  and  the  exposure 
to  the  baneful  influences  of  the  atmosphere  will 
rapidly  destroy  the  granulations  which  had 
already  formed.  However  useful  the  local  and 
general  bath  is  to  advance  the  cicatrization  of  a 
suppurating  wound,  do  not  generalize  too  much 
and  expect  equally  good  service  from  cleansing 
the  granulations. 

Compound  fractures,  under  the  very  best  condi- 
tions, are  tedious  cases,  and  in  gunshot  injuries 
our  patience  wTill  often  be  taxed  to  the  utmost. 
Despondency  should  not  be  an  element  in  the 
character  of  a  military  surgeon.  We  must  expect 
to  have  a  compound  fracture  under  treatment 
at  least  twice,  if  not^three  times  as  long  as  would 
be  required  to  consolidate  a  simple  fracture. 

Should  the  main  vessel  be  injured,  in  connec- 
tion with  the  fractured  bones,  we  still  have  not 
sufficient  cause  to  sacrifice  the  limb ;  but,  ligating 
the  artery  at  its  bleeding  mouths,  we  treat  the 
fracture  as  if  this  complication  had  not  existed. 
Owing  to  the  free  anastomosis  of  the  blood-vessels 


WHEN    ARE    AMPUTATIONS    REQUIRED  ?  339 

of  the  arm,  mortification  is  not  to  be  feared  when 
a  ligation  is  applied  even  to  the  brachial  artery ; 
a  circuitous  route  soon  supplies  the  needful  nour- 
ishment to  the  parts  beyond.  Should  the  nerves 
as  well  as  the  artery  be  injured,  or  the  principal 
nerves  alone  with  the  bones,  then  the  limb,  even 
when  saved,  would  be  a  useless,  paralyzed  ex- 
tremity, and  its  immediate  removal  will  save  the 
patient  a  long,  tedious,  and  dangerous  convales- 
ence.  In  such  cases,  it  is  our  duty  to  sacrifice 
the  limb  to  diminish  the  risks  to  life. 

The  most  dangerous  fractures  of  the  extremi- 
ties are  those  involving  the  heads  of  the  bones 
and  extending  into  a  joint.  The  synovial  injury 
adds  greatly  to  the  danger  of  the  case,  and  in 
former  times  was  considered  nearly  a  fatal  com- 
plication, as  it  necessitated  an  amputation,  which, 
under  the  ordinary  circumstances  attending  hos- 
pital treatment,  was  not  far  removed  from  an 
early  dissolution.  .Nor  have  we  much  to  boast 
of:  for,  when  amputations  near  the  trunk  are 
required,  notwithstanding  all  the  improvements 
in  modern  science,  we  succeed  but  little  better  in 
checking  the  fearful  mortality.  The  severity  of 
the  symptoms  of  articular  injuries  depend  upon 
the  size  of  the  joint  and  the  character  of  the 
wound.     The    dangers   are    serious    enough   with 


340  SYMPTOMS    OF   JOINT    WOUNDS. 

the  smallest  puncture,  but  when  the  wound  is 
large  and  lacerated,  extensive  local  mischief  and 
constitutional  disturbance  is  sure  to  ensue,  lead- 
ing wuth  certainty  to  the  destruction  of  the  joint, 
and  usually  destroying  the  patient.  Hence,  in 
the  days  of  John  Bell,  the  united  experience  of 
surgeons  considered  wounds  of  joints  mortal. 
Crimean  experience  corroborates  John  Bell's  con- 
clusions, as  no  serious  injury  to  the  large  joints 
recovered  unless  the  limbs  were  amputated  or 
joints  resected.  The  great  fear  is  not  in  the 
serious  injuries,  as  these  cases  are  at  once  operated 
upon.  It  is  in  the  apparently  trivial  cases,  where, 
from  the  very  small  size  of  the  wound,  wTe  hope 
that  no  trouble  will  supervene,  that  violent  in- 
flammation shows  itself  and  life  is  sacrificed. 

A  wounded  joint,  under  the  ordinary  hospital 
treatment,  will  pursue  the  following  course: 

When  a  ball  has  perforated  the  joint,  the  peri- 
od of  reaction  is  not  long  absent.  In  extensive 
wounds  a  great  degree  of  nervous  shock  accom- 
panies the  injury,  the  patient  lying  deadly  pale, 
cold  and  faint.  In  from  twelve  to  twenty-four 
hours,  the  tissues  around  the  articulation  become 
hot,  swollen,  and  painful  ;  inflammation  has 
already  seized  upon  the  synovial  membrane,  and 
will    soon    involve    all    the    structures.      All   the 


SYMPTOMS    OP    JOINT    WOUNDS.  341 

symptoms    rapidly    increase    until    they   become 
excessive.     There   is   no   rest  for  the  weary  suf- 
ferer, who,  in  spite  of  iced  applications,  and  the 
free  use  of  morphine,  with  the  entire  arcana  of 
antiphlogistic  remedies,  writhes  about  in  unmiti- 
gated   agony.     If  the  aperture   leading   into  the 
joint  be  made   by  a  ball  or  piece  of  shell,  the 
synovia  at  first,   and   in   two   or  three  days  pus 
freely  escapes.    Should  the  entrance  into  the  joint 
be    small    or   the   passage    oblique,   the   purulent 
synovia  fills  and  distends  the  joint,  adding  much 
to   the  agony,  which    is   again    increased   by  the 
irregular  spasmodic  contractions  of  the  surround- 
ing muscles.      Accompanying  these  local    symp- 
toms will  be  found  a  high  grade  of  inflammatory 
fever,  with   rigors  determined,  great  gastric  dis- 
tress,   intense    thirst,  excessive    restlessness,   and 
with   such   an   amount  of  constitutional  disturb- 
ance as  sometimes  to  destroy  life  in  a  few  days. 
As   the   disease   advances,   abscesses  form  in  the 
surrounding  tissues  by  extension    of  the   inflam- 
matory  process,    and   in  a   few   days    open    con- 
tinuous   passages    to     the    joint,    from    which    a 
constant   discharge    of    purulent   matter   escapes. 
If   the   patient   is    not    destroyed   in    the     early 
stages  of  the  disease  by  erysipelas,  pyaemia,  etc., 
in   connection  with  the    irritative   fever,  he  falls 


342  NECESSITY    OP    ACCURATE    DIAGNOSIS. 

a  prey  to  hectic,  caused  by  the  continued  drain 
from  the  disorganized  joint;  synovial  membrane, 
cartilages,  and  bones  forming  one  mass  of  dis- 
ease. In  gunshot  wounds  of  joints,  very  rarely 
does  the  patient  escape  with  life  in  military  hos- 
pitals. In  private  practice  he  sometimes  recovers, 
but  even  under  the  most  advantageous  circum- 
stances a  successful  case  is  rarely  seen,  and  then 
usually  with  a  destroyed  anchylosed  joint.  As 
the  results  in  injured  joints  are  so  fatal,  sur- 
geons had,  at  an  early  day,  adopted  amputations 
as  giving  the  only  chance  for  recovery.  In  recent 
years,  conservative  surgery  has  introduced  the 
operation  of  resection  as  affording  not  only  the 
means  of  preserving  life,  but  also  of  saving '  a 
useful  limb. 

The  diagnosis  of  articular  injury  is  usually  evi- 
dent from  the  direction  of  the  wound,  and  from 
the  escape  of  synovia;  at  times,  however,  when 
the  orifice  is  small  and  the  wound  circuitous,  a 
successful  diagnosis  requires  much  experience  and 
close  observation.  When  possible,  a  consultation 
should  always  be  had  over  these  cases.  It  is  in 
these  very  cases  of  doubt,  or  of  apparently  trivial 
injury,  that  the  most  violent  reactionary  symp- 
toms are  met,  and  that  a  fatal  issue  occurs.  If 
left  unoperated  upon,  the  trifling  wound,  perfor- 


TREATMENT    OF    RESECTION.  343 

ating  the  joint,  might  nearly  be  considered  mortal ; 
whilst,  if  the  joint  be  not  implicated,  the  opera- 
tion of  resection  is  not  only  not  called  for,  but 
unnecessarily  risks  the  life  of  the  individual. 
The  urgent  necessity  for  an  accurate  diagnosis 
is  evident. 

For  the  upper  extremity  this  resource  is  par- 
ticularly applicable,  as  resection  is  now  the  rule 
of  practice,  having  superseded  amputation  in  all 
cases  where  the  blood-vessels  and  nerves  around 
the  joint  are  not  involved  in  the  injury.  When 
a  joint  has  in  any  way  been  injured  by  a  gun- 
shot wound,  whether  the  articulation  has  only 
been  opened,  or  the  heads  of  the  bones  form- 
ing it  crushed,  as  soon  as  the  excessive  shock 
under  which  the  patient  may  be  suffering  passes 
off,  we  proceed  at  once  to  operate.  A  primary 
resection  is  as  essential  as  a  primary  amputa- 
tion, and  is  followed  by  as  successful  results. 
It  should  be  performed  within  twenty-four  or 
thirty-six  hours,  or  before  reaction  sets  in.  Such 
cases  do  much  better  could  the  patient  have  been 
transferred  to  the  general  hospital  prior  to  an 
operation,  as  transportation  is  difficult  and  dan- 
gerous immediately  after  the  resection,  from  the 
difficulty  of  securing  the  limb  from  movements. 
Should  the  case  not  come  under  observation  until 


344  TREATMENT    OP    RESECTION. 

reaction  has  come  on,  then  by  general,  mild,  anti- 
phlogistic treatment,  and  ice  bladders  or  cold 
water  dressings  locally,  we  await  the  establish- 
ment of  suppuration,  when  the  operation  might 
be    attempted  with  good  prospects  of  success. 

The  results  of  the  primary  resection  are  more 
successful  than  the  secondary;  and  these  are,  in 
turn,  much  more  likely  to  succeed  than  when  the 
operation  is  performed  during  the  stage  of  febrile 
excitement.  There  are  three  or  four  rules  neces- 
sary in  all  cases  of  resection,  and  which  should 
not  be  forgotten  during  the  operation,  viz  :  Make 
the  incision  for  exposing  the  heads  of  the  bones  in 
that  portion  of  the  extremity  opposite  to  the  main 
blood-vessels  and  nerves,  so  that  these  may  not  be 
exposed  to  injury.  If  possible,  make  the  wound" 
lie  in  the  line  of  the  incision,  and  place  the  incis- 
ions in  such  a  way  as  to  permit  a  continued  drain 
from  the  joint.  Make  these  incisions  free,  so  as 
not  to  cramp  the  operator  in  turning  out  the 
heads  of  the  bones.  An  inch  added  to  the  incis- 
ion does  not  increase  its  serious  character,  and 
hastens  the  operation.  Remove  most  of  the  syno- 
vial membrane,  and  save  as  much  periosteum  as 
possible ;  the  one  is  prone  to  take  on  inflam- 
mation; the  other  makes,  and  will,  to  a  certain 
extent,  reproduce  the  bone.     In  performing  sec- 


i 


TREATMENT    OF    RESECTION.  345 

ondary  resections,  the  removal  of  all  the  diseased 
synovial  membrane  becomes  one  of  the  first  ele- 
ments of  success.  More  successes  are  obtained 
from  resections  of  the  shoulder  joint  than  from 
any  other  articulation,  the  statistical  tables  of  the 
final  results  of  operations  in  favor  of  resection 
being  conclusive  over  amputations. 

The  following  is  the  course  recommended  for 
performing  the  operation  of  resection,  a  substi- 
tute for  amputation  of  the  arm  : — a  U  shaped 
flap,  about  three  inches  in  length,  is  made  of  the 
deltoid  muscle,  on  the  upper  and  outer  por- 
tion of  the  arm ;  if  there  be  any  wound  on 
this  portion  of  the  extremity,  making  one  arm 
of  the  incision  include  the  wound.  The  knife 
passing  directly  to  the  bone,  from  the  clavicle  or 
accromial  process  downward  for  three  inches, 
makes  a  large  flap  of  the  deltoid,  which  is  raised 
by  a  few  touches  of  the  knife.  The  circum- 
flex arteries  are  divided  in  this  first  incision, 
and  should  be  at  once  ligated,  otherwise,  as  they 
are  of  considerable  size,  the  patient  will  lose 
much  blood,  and  the  steps  of  the  operation  ob- 
scured. By  carrying  the  arm  over  the  chest,  the 
capsule  of  the  joint  is  exposed  and  divided  trans- 
versely, and  with  it  the  rotary  muscles  of  the 
shoulder,  when  the  head  will  protrude   from  its 


34(3  TREATMENT    OP    RESECTION. 

position.  The  long  head  of  the  biceps  is  carefully 
removed  from  its  bicepital  groove  and  protected 
from  injury.  The  bones  are  now  examined  ;  a 
knife  blade,  or  spatula,  as  a  guard,  is  placed  behind 
the  bone  so  as  to  protect  the  soft  parts  and  vessels 
from  injury,  and  all  of  the  injured  portion  is 
removed.  When  the  ball  has  entered  directly 
within  the  joint,  only  the  surface  may  require 
excision ;  but  should  the  head  of  the  bone  be 
extensively  spiculated,  we  must  cut  back  to  the 
sound  bone,  even  if  we  are  compelled  to  remove 
four  or  five  inches  of  the  shaft  of  the  bone,  as 
was  successfully  done  by  Stromyer  for  a  gunshot 
injury:  should  the  glenoid  cavity  be  equally  in- 
jured, the  fractured  portion  is  removed.  The  rule 
is,  never  to  remove  more  of  the  bone  than  is  abso- 
lutely called  for,  and  not  to  open  the  medullary 
cavity  if  it  can  in  an}7  way  be  avoided. 

When  the  wound  has  been  cleansed  of  all  for- 
eign bodies,  the  flap  is  replaced  and  secured  with 
one  or  two  points  of  suture.  As  adhesion  by  the 
first  intention  is  not  usually  expected,  and  gives 
no  advantage  over  the  final  result  by  granulation, 
nice  adjustment  is  not  necessary.  The  patient  is 
then  put  to  bed  and  cold  water  dressings  applied. 
Inflammation  at  first  runs  high,  the  parts  around 
the  joint  are  much  swollen,  and  a  collection  soon 


TREATMENT    OF   RESECTION.  347 

forms  within  the  cavity  from  which  the  bones  have 
been  removed.  The  escape  of  this  decomposed 
blood  and  pus  from  the  wound  gives  great  relief. 
"When  kept  in  by  the  too  nice  adjustment  of  the 
flap,  the  collection  increases  the  swelling,  oedema, 
and  pain  which  it  diffuses  over  the  neighboring- 
parts,  involving  the  chest  as  well  as  arm.  When 
suppuration  becomes  established,  the  swelling  and 
pain  subside  ;  granulations  spring  up,  and  even- 
tually close  the  wound.  In  the  meantime  the 
divided  muscles  have  formed  new  relations  by  a 
lymphy  exudation;  they  become  more  or  less 
incorporated  with  the  surrounding  tissues,  and  by 
taking  an  insertion  around  the  cut  portion  of  the 
bone,  form  in  time  a  closed  capsule.  A  head  to 
the  bone  is  sometimes,  in  a  measure,  formed; 
in  other  cases  the  head  of  the  bone  becomes 
attached  to  the  cavity  by  fibrinous  bands.  Of 
the  cases  of  resection  of  the  shoulder  performed 
in  the  Crimea  but  few  died ;  and  all  those  saved 
regained  a  useful  limb,  possessing  all  the  motions, 
with  the  exception  of  those  of  the  deltoid,  which 
muscle  is,  to  a  certain  extent,  paralyzed  from 
the  division  of  its  nerves,  which  cannot  altogether 
be  avoided  in  exposing  the  head  of  the  bone. 

As   suppuration   will   be   excessive,    and    often 
long-continued,    nourishment    and    even    stimuli 


348  TREATMENT    OF   RESECTION. 

may  be  demanded  during  the  treatment.  When 
abscesses  form  in  the  surrounding  cellular  tissue 
they  should  be  open.  It  is  a  matter  of  but  little 
importance  in  what  position  the  limb  is  placed, 
and  how  it  is  secured,  provided  its  position  is 
comfortable  to  the  sufferer.  The  uneasiness  and 
irritation  which  the  splints  and  bandages  give,  do 
much  to  prevent  success.  It  matters  little  what 
length  of  limb  the  patient  has,  provided  his  life 
be  saved,  and  the  convalescence  be  speedy.  A 
shortened  arm  does  not  affect  its  usefulness,  and 
a  slightly  changed  direction  can  be  corrected  in 
the  after-stages  of  the  treatment.  The  most 
effectual  management  is  the  simplest,  and  tedious 
daily  dressings  are  to  be  discouraged;  straighten- 
ing the  limb  upon  the  bed,  a  pillow,  or  a  long, 
broad  splint,  without  bandaging,  being  the  best 
and  most  comfortable  dressing  for  any  resec- 
tion. The  patient  is  kept  in  bed  until  the  sup- 
purative stage  is  established,  when  he  will  be 
permitted  to  get  up.  His  arm  is  then  placed  in  a 
sling,  and  the  water  dressings  are  continued  until 
a  complete  cure  is  effected.  When  the  parts  are 
nearly  cicatrized,  it  will  be  time  enough  to  apply 
the  tumefaction  bandage,  for  removing  the  oedema 
of  the  limb.  Anchylosis  rarely  follows  this  oper- 
ation   in   the    shoulder-joint.     As  a  proof  of  the 


' 


TREATMENT    OF   RESECTION.  349 

efficacy  of  resection,  Stromyer  excised  nineteen 
shoulder-joints  with  a  loss  of  seven,  chiefly  from 
pyamiia.  Of  eight  cases  in  which  the  operation 
was  required,  but  from  some  mitigating  circum- 
stances was  not  performed,  five  died. 

Gunshot  wounds  in  the  neighborhood  of  the 
elbow-joint  are  much  more  readily  recognized  by 
the  escape  of  the  synovia,  etc.,  than  injuries 
of  the  shoulder.  Inflammatory  reaction  runs  high, 
as  in  all  cases  in  which  the  joints  have  been 
opened  by  a  ball.  Collections  soon  form,  and 
the  excessive  swelling  stretches  the  softened  cap- 
sule, which,  giving  way,  allows  of  the  burrowing 
of  pus  and  final  discharge  through  open  abscesses. 
After  running  a  tedious,  painful,  and  dangerous 
course,  if  the  patient  escapes  with  a  shattered 
constitution  and  an  anchylosed  limb,  he  is  fortu- 
nate. A  primary  resection  offers  a  diminution  of 
the  risks  to  life,  a  rapid  convalescence,  and  a 
movable  joint.  In  the  Schleswig-Holstein  army, 
of.  fifty-four  amputations  of  the  arm  nineteen 
died,  whilst  of  forty  resections  under  similar 
circumstances  only  six  died.  The  results  of  the 
operations  were  also  modified  by  the  period  of 
performing  the  resection.  Of  eleven  cases  ex- 
cised within  twenty-four  hours  before  reaction 
ensued,  but  one   died  ;    of  twenty  cases  between 


350  RESECTING    ELBOW-JOINT. 

the  second  and  fourth  day,  or  during  the  stage 
of  irritation  or  excitement,  four  died;  and  of  nine 
cases  operated  upon  between  the  eighth  and 
thirty-seventh  day,  only  one  died :  an  exempli- 
fication of  a  general  rule  laid  down  in  the  com- 
mencement of  this  chapter,  that  the  wounded 
bear  operations  before  the  stage  of  reaction,  or 
after  the  establishment  of  suppuration,  much 
better  than  they  do  whilst  suffering  under  high 
inflammatory  excitement.  This  showrs  the  neces- 
sity of  deferring  operations. 

The  elbow-joint,  for  gunshot  wounds,  transfix- 
ing its  capsule  and  fracturing  the  bones,  is  best 
resected  from  the  back  of  the  joint,  the  patient 
lying  upon  his  abdomen.  An  H,  L,  or  T  incision, 
taking  in  the  breadth  of  the  articulation,  when 
sufficiently  long,  will  expose  perfectly  the  heads 
of  the  bones.  There  are  no  important  vessels  on 
this  posterior  portion  of  the  arm,  and  only  one 
nerve,  the  ulna,  which  must  be  sought  on  the 
inner  side  and  avoided  in  the  incision,  or  paralysis 
of  all  the  muscles  supplied  by  it  will  follow  its 
section.  "When  the  posterior  ligaments  are  divid- 
ed, and  the  joint  exposed,  only  remove  the  frac- 
tured head  and  all  foreign  bodies,  and  do  not 
interfere  with  that  bone  which  has  not  been 
injured.     The  lips  of  the   wound   are    closed  by 


HAND   RARELY   REQUIRES    AMPUTATION.  351 

sutures,  and  cold  water  dressings  become  the 
principal  treatment.  The  limb  is  placed  upon 
pillows,  and  not  disturbed,  if  possible,  until  sup- 
puration is  established.  "When  the  soft  parts  are 
cicatrizing,  and  healing  is  nearly  completed,  pas- 
sive motions  in  the  joint  will  prevent  anchylosis, 
and  a  tumefaction  bandage  will  remove  the 
oedema  of  the  limb.  Instances  of  good  results 
are  recorded  for  injuries  at  the  wrist-joint,  where 
the  spiculated  ends  of  both  radius  and  ulna  have 
been  satisfactorily  removed;  also,  instances  in 
which  either  of  these  bones  have  been  removed 
entire,  for  chronic  ostitis  and  necrosis  brought 
on  from  gunshot  injuries.  Similar  incisions  to 
those  recommended  for  the  resection  of  the 
elbow-joint  will  expose  the  heads  of  the  wrist- 
bones,  and  permit  of  the  ready  removal  of  any 
injured  portion.  In  this  as  in  all  other  cases,  we 
must  save  all  tendons  passing  over  a  joint  to  sup- 
ply distant  bones;  and  in  the  wrist  particularly, 
many  of  the  muscles  which  supply  the  fingers  can 
be  drawn  out  of  the  way  and  thus  escape  injury. 
However  frightful  an  injury  involves  the  hand, 
it  is  very  seldom  that  it  is  so  mangled  as  to  be 
beyond  the  pale  of  surgical  skill,  and  unless  it  is 
literally  ground  up  it  should  not  be  amputated. 
In  certain    cases,  fingers   may  have  been  already 


352  INJURIES    TO    INFERIOR    EXTREMITY. 

torn  off",  or  may  be  hanging  by  a  fragment  of 
skin,  when  they  should  be  removed;  but  for  ordi- 
nary guDshot  lacerations  of  the  hand,  amputation 
of  the  entire  hand  is  very  rarely  required.  Dif- 
ferent bones  of  the  hand  and  wrist  are  to  be 
removed  when  irrevocably  injured,  with  or  with- 
out the  metacarpal  bones  of  the  fingers  or  the 
thumb.  Any  fingers  which  can  be  saved  will  be 
better  than  the  best  artificial  limb.  In  cases  of 
lacerated  hands  in  military  surgery,  when  attempts 
are  made  to  save  the  limb,  under  cold  water  dress- 
ings, the  inflammation  which  comes  on  makes 
a  shocking  limb  to  those  unaccustomed  to  treat 
lacerations  of  this  extremity;  but  at  the  end  of 
eight  or  ten  days,  when  suppuration  has  been 
well  established  and  granulations  are  forming,  the 
swelling  subsides,  the  torn  portions  are  drawn 
together,  cicatrization  advances  rapidly,  and  often 
but  little  deformity  remains :  at  least  the  patient 
retains  a  useful  limb.  Some  surgeons  lay  down 
the  rule,  that  an  amputation  of  the  hand  is  never 
imperative,  however  frightful  the  injur}7  to  it  may 
appear ;  and  there  is  much  truth  in  the  assertion. 

In  the  inferior  extremity,  we  find  the  treatment 
of  gunshot  injuries  somewhat  different  from  those 
of  the  upper  limb,  on  account  of  the  minor  degree 


HIP-JOINT    INJURIES. 


353 


of  vascularity,  and  the  much'  greater  tendency  to 
mortification,  so  that  the  rule  to  which  we  called 
attention,  of  amputations  being  rarely  required 
for  the  superior  extremity,  is  reversed  for  the  leg, 
where  it  is  often  the  only  way  of  escape  left  to 
save  the  life  of  the  wounded. 

We  have  elsewhere  stated  that  when  balls 
embed  themselves  in  the  pelvic  bones,  and  their 
position  can  be  discovered,  provided  a  serious 
operation  is  not  needed,  they  should  be  removed, 
as  their  presence  will,  sooner  or  later,  give  rise 
to  trouble  ;  and  also  that  all  loose  spiculse  should 
be  taken  away.  Sequestra  frequently  show  them- 
selves from  time  to  time  during  the  treatment, 
and  are  withdrawn.  When  the  ball  strikes 
lower  down,  in  the  neighborhood  of  the  tro- 
chanters, it  usually  splinters  the  bone,  and 
frequently  involves  the  ilio-femoral  articulation. 
Such  injuries  are  of  the  most  serious  char- 
acter, and  are  usually  considered  fatal.  It  is  a 
question  of  much  moment  to  inquire,  how  can 
modern  surgery,  with  all  of  its  appliances,  im- 
provements and  experience,  assist  in  saving  the 
life  and  limb  of  such  seriously  wounded?  Within 
a  few  years  the  rule  for  all  compound  fractures 
of  the  femur  was  amputation  of  the  limb;  but  the 
statistics  from  military  hospitals  in  time  of  war 
.jo 


354  HIP-JOINT-  INJURIES. 

are  so  frightful — but  few  successes  for  the  num- 
bers treated  —  that  it  was  naturally  suggested  that 
the  risks  could  not  be  materially  increased  by 
letting  the  patient  take  the  chances  with  his  limb 
on  ;  when,  if  his  life  was  saved,  it  would  be  with, 
and  not  without  his  leg.  This  has  settled  down 
into  a  conviction  for  fractures  of  the  upper  third 
of  the  femur,  which  are  now  treated  without 
amputation,  inasmuch  as  nearly  every  amputation 
in  the  neighborhood  of  the  trochanter  and  all  at 
the  hip-joint  are  fatal.  If  we  are  assured  that  the 
ball  has  crushed  the  head  of  the  bone,  then  the 
operation  of  resection  offers  the  best  prospects 
of  success  for  the  patient;  but  it  does  not  always 
follow  that  this  diagnosis  can  be  clearly  made 
out,  if  the  signs  of  intra-capsular  fracture  be  not 
present.  Military  surgical  experience  shows,  that 
a  fracture  of  the  upper  portion  of  the  shaft  of  a 
bone  does  not  necessarily  extend  into  the  head, 
and  vice  versa.  Unless  the  junction  of  the  epiphy- 
sis with  the  shaft  is  struck,  the  fracture  is  more 
apt  to  be  confined  to  a  centre  of  ossification,  so 
that,  in  the  thigh  as  in  the  arm,  a  blow  just  below 
the  trochanter  will  not  usually  fracture  the  head 
of  the  femur.  When  the  joint  is  opened  and  the 
head  of  the  bone  fractured,  the  wound  should  be 
enlarged,    or    an    opening    made    into   the   joint 


HIP-JOINT    INJURIES.  355 

from  the  outer  side  of  the  hip,  by  which  the  frac- 
tured head  might  be  removed.  If  any  success  is 
hoped  for,  those  cases  alone  should  be  selected 
in  which  neither  blood-vessels  nor  nerves  are 
injured,  nor  the  soft  parts  extensively  torn.  If 
all  or  any  of  such  are  injured,  where  experience 
teaches  us  that  the  chances  from  successful  resec- 
tion are  more  than  doubtful,  do  not  have  recourse 
to  amputation  which  is  so  certainly  fatal,  but  let 
the  patient  live  his  few  remaining  hours  or  days 
without  being  haunted  by  the  ghost  of  a  useless 
operation.  Should  he  revive  the  reactionary 
stage,  and  still  retain  a  good  pulse  and  compar- 
atively unshattered  constitution,  then  a  secondary 
operation  might  give  a  chance  of  success.  In 
the  Crimean  service,  no  amputation  in  the  vicin- 
ity of  the  hip-joint  was  successful — every  indi- 
vidual case  died.  This  only  corroborates  the 
experience  of  other  campaigns,  and  shows  the 
inutility  of  such  mutilations.  When  death,  from 
a  crushed  thigh-joint  is  inevitable,  it  is  hardly 
humane  to  amputate  under  the  plea  of  giving  the 
patient  the  benefit  of  the  chances  which  experi- 
ence teaches  us  are  nugatory. 

As  regards  resections  in  suitable  cases,  the  re- 
port is  a  little  more  satisfactory.  Of  six  resec- 
tions performed  by  the  English  surgeons  in  the 


354  HIP-JOINT    INJURIES. 

are  so  frightful — but  few  successes  for  the  num- 
bers treated  —  that  it  was  naturally  suggested  that 
the  risks  could  not  be  materially  increased  by 
letting  the  patient  take  the  chances  with  his  limb 
on  ;  when,  if  his  life  was  saved,  it  would  be  with, 
and  not  without  his  leg.  This  has  settled  down 
into  a  conviction  for  fractures  of  the  upper  third 
of  the  femur,  which  are  now  treated  without 
amputation,  inasmuch  as  nearly  every  amputation 
in  the  neighborhood  of  the  trochanter  and  all  at 
the  hip-joint  are  fatal.  If  we  are  assured  that  the 
ball  has  crushed  the  head  of  the  bone,  then  the 
operation  of  resection  offers  the  best  prospects 
of  success  for  the  patient;  but  it  does  not  always 
follow  that  this  diagnosis  can  be  clearly  made 
out,  if  the  signs  of  intra-eapsular  fracture  be  not 
present.  Military  surgical  experience  shows,  that 
a  fracture  of  the  upper  portion  of  the  shaft  of  a 
bone  does  not  necessarily  extend  into  the  head, 
and  vice  versa.  Unless  the  junction  of  the  epiphy- 
sis with  the  shaft  is  struck,  the  fracture  is  more 
apt  to  be  confined  to  a  centre  of  ossification,  so 
that,  in  the  thigh  as  in  the  arm,  a  blow  just  below 
the  trochanter  will  not  usually  fracture  the  head 
of  the  femur.  When  the  joint  is  opened  and  the 
head  of  the  bone  fractured,  the  wound  should  be 
enlarged,    or    an    opening    made    into   the   joint 


HIP-JOINT    INJURIES.  355 

from  the  outer  side  of  the  hip,  by  which  the  frac- 
tured head  might  be  removed.  If  any  success  is 
hoped  for,  those  cases  alone  should  be  selected 
in  which  neither  blood-vessels  nor  nerves  are 
injured,  nor  the  soft  parts  extensively  torn.  If 
all  or  any  of  such  are  injured,  where  experience 
teaches  us  that  the  chances  from  successful  resec- 
tion are  more  than  doubtful,  do  not  have  recourse 
to  amputation  which  is  so  certainly  fatal,  but  let 
the  patient  live  his  few  remaining'  hours  or  days 
without  being  haunted  by  the  ghost  of  a  useless 
operation.  Should  he  revive  the  reactionary 
stage,  and  still  retain  a  good  pulse  and  compar- 
atively unshattered  constitution,  then  a  secondary 
operation  might  give  a  chance  of  success.  In 
the  Crimean  service,  no  amputation  in  the  vicin- 
ity of  the  hip-joint  was  successful — every  indi- 
vidual case  died.  This  only  corroborates  the 
experience  of  other  campaigns,  and  shows  the 
inutility  of  such  mutilations.  When  death,  from 
a  crushed  thigh-joint  is  inevitable,  it  is  hardly 
humane  to  amputate  under  the  plea  of  giving  the 
patient  the  benefit  of  the  chances  which  experi- 
ence teaches  us  are  nugatory. 

As  regards  resections  in  suitable  cases,  the  re- 
port is  a  little  more  satisfactory.  Of  six  resec- 
tions performed  by  the  English  surgeons  in  the 


356  HIP-JOINT    INJURIES. 

Crimea,  one  was  successful,  and  the  condition  of 
all  operated  upon  was  made  more  comfortable. 
Had  the  conveniences  for  treatment  been  greater, 
and  the  general  sanitary  condition  of  the  troops 
better,  with  less  p3Tsemia,  hospital  gangrene  and 
scurvy,  much  better  results  might  have  been  ob- 
tained. So'me  of  the  cases  were  doing  well,  with 
every  prospect  of  final  success,  when  they  were 
swept  off  by  one  of  the  above  diseases.  In  ampu- 
tations at  the  hip-joint,  all  the  cases  died  speedily. 

In  cases  of  resection,  the  greatest  difficulty  lies 
in  the  after-treatment.  As  it  is  not  expected  to 
restore  a  perfect  limb,  no  good  result  can  be  ob- 
tained by  using  violent  extension.  The  leg,  how- 
ever, must  be  fixed,  to  facilitate  those  movements, 
in  changing  position,  which  are  necessary  to  the 
patient's  comfort.  A  long,  straight  splint  is  used 
for  this  purpose  by  some  surgeons,  whilst  the 
incline-plane,  which  I  would  much  prefer,  is  de- 
pended upon  by  others.  Some  have  bandaged  the 
limb  to  the  sound  one,  and  speak  of  it  as  a  good 
mode  of  support.  Water  dressings  compose  the 
local  treatment. 

Baudens  succeeded  in  saving  both  limb  and  life 
in  cases  in  which  compound  fractures  of  the  upper 
half  of  the  thigh  were  treated  without  operation. 
Consolidated   and    useful    limbs,    with   but    little 


HIP-JOINT    INJURIES.  357 

deformity,  are  reported  as  having  been  saved. 
By  the  use  of  the  fracture  box  and  incline-plane, 
he  succeeded  in  curing  a  compound  fracture  on  a 
level  with  the  trochanter,  saving  a  useful  limb, 
although  he  had  extracted  two  inches  of  the  shaft 
of  the  femur.  His  experience  proves  that  com- 
pound comminuted  fractures  of  the  upper  half 
of  the  thigh  are  not  so  fatal  when  attempts  are 
made  to  save  the  limb  as  when  the  thigh  is  ampu- 
tated. 

As  the  resection  of  the  hip  is  so  much  more 
successful  when  performed  for  disease  than  for 
injury,  it  has  been  suggested  by  surgeons  of  expe- 
rience, that  an  exception  to  the  rule  of  immediate 
resections  be  made  for  the  hip-joint,  and  that 
such  cases,  even  the  most  suitable  for  the  opera- 
tion, be  deferred  until  suppuration  be  well  estab- 
lished. For  hip-joint  resections,  it  is  said  that 
nothing  is  lost  by  this  delay,  whilst,  on  the  con- 
trary, there  may  be  a  chance  of  saving  the  limb 
without  an  operation.  Larrey,  in  1812,  reported 
six  cases  of  gunshot  fractures  of  the  neck  of  the 
femur,  with  three  cures,  showing  that  the  pros- 
pects are  not  altogether  hopeless.  When  the  pa- 
tient is  in  a  measure  placed  in  similar  conditions 
to  those  affected  with  diseases  of  the  bones,  his 
prospect  for  a  successful  resection  appears  to  be 


358 


IIIP-JOINT    INJURIES. 


improved.  Baudens  says,  that  as  the  resection  of 
the  hip-joint  only  succeeds  as  a  secondary  opera- 
tion, attempts  should  first  be  made  to  save  the 
limb. 

We  preface  the  following  table,  taken  from  Ar- 
mand's  Histoire  Medico-Chirurgicale  de  la  Guerre 
de  Crimee,  with  the  sug-crestion  that  anv  surgeon 
who  has  ever  had  a  successful  case  of  resection  at 
the  hip-joint,  has  always  been  eager  to  publish  it; 
whilst  many  have  been  disposed  to  hide  their 
misfortunes  from  the  public,  so  that  the  tables, 
showing  the  relative  advantages  of  primary  and 
secondary  resections,  appear  in  their  very  best 
light. 

PRIMARY  RESECTIONS  AFTER   GUNSHOT  WOUNDS. 


Surgeons  : 


Operated 
upon. 


Cures. 


Deaths. 


Larrey.     (Volume  3,  Clinique) 

J.  Cooper.     (Dictionary) 

Leteille.     (Relatione  du  Siege  d'Anvers,  par 

M.  H.  Larrey) 

Hutin.     (Memoires  de  Medicine  et  de  Chi- 

rurgie  Militaires) 

Sedillot.    (Annales  de  la  Chirurgie  Fraucaise 

et  Etrangere) 

G-oyon.     (Expedition  de  Churchill,  Algerie) 

Rochet.     (Journees  de  Juiu,  1S4S) 

ftubiot.     (These  de  Montpellier,  1840).    ... 

French  Crimean  Service 

McLeod.     (Crimean  War) 

Stromyer 


6 

2 

1 

2 

5 

1 

1 

9 

5 

1« 

1 

36 

1 

5 
1 
1 

3 
9 
4 
1 

35 


*  This  successful  case  was  found,  after  the  articulation  had  been  laid  opeu.  not 
to  be  a  fracture  extending  within  the  joint,  but  confined  without  the  capsule:  and 
we  arc.  therefore,  justified  in  the.  belief  that  the  case  would  have  done  equally 
well  without  the  resection. 


COMPOUND    FRACTURE    OF    THIGH. 


359 


1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

3 

1 

1 

12 

3 

SECONDARY  OPERATIONS  FROM   GUNSHOT  WOUNDS. 


Larrey.     (Clinique,  volume  5) 

Guthrie.     (Clinic,  volume  5) 

Baudens.     (Traite  des  Plaies  d'Armes  a  feu) 
Ferussac.     (Bulletin  des  Science  Medicales. 

volume^) 1  ••  1 

Robert.     (Journee  de  Juin,  1848) 1  ..  1 

Guersant.     (Journees  de  Juin,  1848) 1  ..  1 

Vidal.     (Traite  de  Chirurgie) 1  ..  1 

Mounier.     (Constantinople,  1S54) 3  •.  3 

Legouest.     (Constantinople,  1854) 1  ..  1 

McLeod.     (Crimean  War) 


It  has  been  suggested,  that  if  the  patient  who 
has  been  operated  upon  could  have  facilities  for 
slinging  the  whole  body,  it  wTould  afford  many 
advantages  in  the  management  of  excisions  of 
the  hip-joint. 

A  compound  fracture  in  the  upper  third  of  the 
thigh  should  be  treated  in  every  respect  as  if  in 
the  arm.  Unless  the  leg  is  so  mangled  that  an 
amputation  is  an  act  of  necessity,  it  should  not  be 
thought  of.  We  have  already  said  that,  in  field 
military  surgery,  amputation  near  the  trunk  is 
synonymous  with  death.  The  treatment  must 
commence  on  the  battle  field  by  proper  transpor- 
tation; as  the  judicious  removal  of  fractured  limbs 
is  as  important  as  an  operation,  and  any  neglect  in 
this  department  will  deprive  the  wounded  man  of 
all  hope  of  retaining  his  limb,  or  often  of  having 
his  life  saved.     We  will  carefully  remove  all  loose 


360  COMPOUND    FRACTURE    OF    THIGH. 

and  movable  spiculre,  dilating  the  wounds  if  neces- 
sary, to  facilitate  the  thorough  cleansing  of  all 
foreign  bodies.  Until  suppuration  is  well  estab- 
lished, the  limb  is  kept  in  an  easy  position  and  sur- 
rounded with  cold  applications.  All  tight,  reten- 
tive bandages  are  to  be  rejected,  as  they  interfere 
with  topical  antiphlogistic  applications.  Dispense 
with  bandages.  On  the  eighth  or  tenth  day,  when 
the  reactionary  stage  has  passed,  the  wound  is 
again  to  be  examined  for  foreign  bodies,  and  all 
portions  of  bone  which  may  have  become  separ- 
ated by  the  inflammatory  process  must  be  re- 
moved ;  or  as  sequestra,  they  will  become  incor- 
porated in  the  new  osseous  formations,  and  be 
the  cause  of  much  trouble  and  suffering. 

In  all  compound  fractures,  with  much  loss  of 
bone,  it  is  always  injurious  to  attempt  to  obtain 
a  limb  of  equal  length  with  the  sound  one.  It 
cannot  be  done,  and  the  chafing  and  annoyance  of 
splints  and  tight  bandaging  may  react  very  seri- 
ously, if  not  fatally  upon  the  constitution.  The 
first  thing  to  be  attended  to  is  the  facilities  for 
treating  such  a  fracture.  If  we  are  striving  for 
successful  results,  we  must  not  expect  to  obtain 
them  if  a  patient,  with  a  compound  fracture  of  the 
thigh,  is  being  treated  upon  the  ground  or  is  lying 
upon  a  little  straw.     He  must  have  a  proper  bed 


COMPOUND    FRACTURE    OF    THIGH.  361 

and  a  good  firm  mattress,  prepared  with  a  bed-pan 
hole,  for  facilitating  nature's  daily  wants  without 
the  necessity  of  moving  him.  Upon  this  the 
patient  is  placed,  lying  on  his  back,  with  the  leg 
extended.  Two  long  straps  of  diachylon  plaster 
are  attached  to  the  sides  of  his  leg  from  the  knee 
to  the  ankle ;  they  form  a  loop  under  the  foot,  and 
a  weight  is  swung  from  this  over  the  foot  of  the 
bed.  This  will  be  sufficient  to  tire  the  muscles 
and  make  the  necessary  degree  of  extension  ;  or 
the  limb  might  be  loosely  attached  to  a  long  thigh 
splint.  The  tumefaction  roller  is  inadmissible, 
and  strips  of  adhesive  plaster,  or  strips  of  bandage, 
will  secure  the  limb  to  the  splint,  and  at  the  same 
time  leave  the  wound  open  for  inspection  and 
dressing.  For  the  first  week  or  ten  days  this  will 
be  all  the  apparatus  needed.  As  the  case  ad- 
vances, splints  may  be  more  methodically  applied 
by  using  long  inner  and  outer  splints  of  light 
board,  well  padded  with  loose  cotton,  and  secured 
in  position  by  bands  of  adhesive  plaster  or  with 
tapes.  The  counter-extending  bands  are  made  by 
adhesive  strips  attached  to  the  sides  of  the  leg 
and  carried  under  the  foot,  where  they  are  secured 
to  the  end  of  the  splint.  Allow  the  ends  of  the 
bones  to  fill  up  the  void  made  by  the  extraction 
31 


362  COMPOUND    FRACTURE    OF    THIGH. 

of  the  spicule,  as  this  hastens  consolidation. 
With  the  exception  of  the  mechanical  appliances 
for  the  broken  bone,  the  case  is  treated  as  for  a 
long-continuous  suppurating  wound,  by  avoiding, 
in  all  cases,  depletion  and  by  giving  liberal  diet. 
Many  of  these  cases  will  die  ;  but  if  we  have 
facilities  in  a  well-ventilated  and  well-organized 
hospital,  we  will  have  the  satisfaction  of  saving 
some  of  the  patients  submitted  to  our  care. 

In  fractures  of  the  middle  and  lower  third 
of  the  thigh,  not  implicating  the  knee-joint,  the 
question  will  again  occur  —  what  course  is  to  be 
pursued  with  them  ?  These  are  still  very  serious 
cases,  and  are  classed  with  those  of  the  upper 
third.  Where  attempts  are  made  to  save  them, 
as  recommended  by  Guthrie,  the  fatality  will  not 
be  very  dissimilar  to  fractures  nearer  the  trunk, 
and  the  moderate  success  which,  under  the  very 
best  circumstances,  we  will  obtain,  will  depend 
upon  the  state  of  health  of  the  sufferer  and  the 
conveniences   for  treatment. 

There  are  cases  which  often  appear  so  trivial — 
only  a  small  bullet  hole  leading  to  the  crushed 
bone — that  it  seems  barbarous  surgery  to  con- 
demn the  limb  without  an  attempt  at  saving  it. 
The  young  military  snrgeon  expects  much  from 
conservative  surgery  in   such  cases.     We  are  in- 


i 


i 


COMPOUND    FRACTURE   OF   THIGH.  363 

formed  by  the  experienced,  that  this  striving 
after  conservatism  is  the  main  canse  of  the  heavy 
mortality.  Surgeons  generally  are  not  prepared 
to  believe  how  hopeless  compound  fractures  of 
the  thigh  are,  until  the  unwelcomed  truth  is 
forced  upon  them  by  an  ever-recurring  expe- 
rience, that  many  lives  are  sacrificed  to  attempts 
at  saving  these  broken  limbs.  In  civil  surgery, 
or  with  every  facility  in  military  hospitals,  we 
should  attempt  to  save  the  limb — it  is  the  proper 
course  to  pursue ;  but  on  the  battle  field,  with 
the  deteriorated  material  upon  which  we  are 
operating,  and  the  poisoned  atmosphere  of  the 
wards  into  which  the  patient  is  to  be  carried,  it 
is  a  fatal-  error.  Military  surgeons  must  abandon 
their  conservative  intentions  to  expediency.  It 
is  for  such  cases  that  primary  amputation  of- 
fers the  best  chances  for  life.  In  rejecting  am- 
putations we  lose  more  lives  than  we  save  limbs. 
As  a  rule,  amputations  are  less  hazardous  the 
greater  distance  we  operate  from  the  trunk,  and 
the  reason  why  amputations  are  urged  for  com- 
pound fractures  of  the  lower  and  not  upper  por- 
tions of  the  femur  is,  that  the  chances  being 
similar  without  it,  amputations  are  much  less  fatal 
in  the  lower  than  in  the  upper  half  of  the 
thigh. 


364  PERFORATIONS    OF   THE    KNEE-JOJNT. 

Resection  of  the  shaft  of  the  femur  for  a 
crushing  of  the  bone  has  been  often  recom- 
mended and  as  often  practiced,  but  the  expe- 
rience of  latter  years  discourages  its  performance, 
as  the  operation  is  more  serious  than  the  con- 
dition for  which  the  remedy  is  used.  When 
the  splinters  of  bone  are  removed,  there  is  con- 
siderable space  for  the  play  of  the  rough  edges 
remaining,  and  which,  therefore,  give  but  little 
trouble. 

Should  w.e  attempt  to  save  a  fractured  thigh 
in  its  lower  third,  we  may  use  either  the  straight 
splint  or  the  double  incline-plane.  The  latter 
is  much  the  more  comfortable  position  for  the 
patient,  but  has  the  disadvantage  of  promoting 
the  burrowing  of  pus,  which,  in  working  its  way 
down  the  limb,  may  dissect  passages  for  itself 
as  far  as  the  buttock,  and,  by  its  multiplied 
openings,  cause  much  annoyance  as  well  as  much 
destruction  to  bones  and  muscles.  Surgeons  in 
the  Crimea  often  had  cause  to  regret  attempts 
at  saving  fractured  thighs,  but  never  regretted 
an  early  amputation. 

When  the  knee-joint  is  implicated  in  a  shot 
wound,  or  cut  open  by  a  shell,  with  injury  to 
the  head  of  the  tibia  or  femur,  experience  has 
shown  that,  however   trivial   the  wound  may  ap- 


PERFORATIONS    OF    THE    KNEE-JOINT.  805 

pear,  if  the  synovial  sac  he  entered,  and  air  he 
admitted,  or  a  foreign  body  lie  within  the  joint, 
violent  synovitis,  with  great  pain,  swelling  and 
heat,  and  with  excessive  inflammatory  fever,  will 
come  on  after  twenty-four  or  thirty-six  hours. 
Should  the  patient  survive  the  inflammatory  stage, 
erysipelas,  pyaemia  or  hectic  will  ultimately  de- 
stroy life  ;  and  although  on  the  other  hand,  the 
effusions  may  he  absorbed,  and  a  good  anchylosed 
limb  saved,  it  is  a  very  rare  occurrence.  If  the 
soft  parts  are  not  much  lacerated,  or  the  blood- 
vessels and  nerves  behind  the  joint  injured,  such 
cases  are  well  adapted  for  resection,  and  excel- 
lent results  are  obtained  in  practice. 

A  straight  or  elliptical  incision  over  the  an- 
terior portion  of  the  joint,  across  its  entire 
diameter,  will  expose  the  interior,  and  enable 
the  surgeon  to  remove  the  foreign  bodies,  what- 
ever they  may  be,  and  with  them  the  head  of  the 
injured  bones.  The  section  of  the  bones  should 
be  made  in  such  a  way  that  the  surfaces  will 
adapt  themselves  to  each  other.  When  the  ex- 
ternal wound  is  closed  by  sutures,  union  by  the 
first  intention  may,  to  a  certain  extent,  be 
obtained.  In  the  successful  cases,  the  bones 
eventually  become  firmly  united,  and,  with  an 
anchylosed    joint,    the    patient    retains   a   useful 


866  TREATMENT    OP    INJURED    JOINTS. 

limb.     After  the   resection,  a   long   splint   upon 
the  back  of  the  leg,  reaching  from  the  buttock 
to  the  heel,  is  all  the  apparatus  required,  whilst 
cold   water   dressings   are   alone   applied   around 
the  joint.      In    cases    of    resection,    the    surgeon 
must  not  expect  quick  union  in  the  wound,   as 
that   does   not   often    occur   in   military   surgery. 
A  tedious   suppuration,   the  formation  of  nume- 
rous abscesses,  and  often  the  exfoliation  of  por- 
tions   of    bone   is    the    rule,    requiring   care   and 
judicious  management  to  obtain  a  final  success; 
many  of   those  operated  upon  being  lost  by  the 
action  of  those  deleterious  causes  which  act   in- 
juriously upon  all  wounds  in  military  hospitals. 
When  attempts  are  made  to  save  the  limb  in 
what  we  suppose  to  be  a  trivial  or  doubtful  case 
of  knee-joint   injury,    we    should    use   all  of  the 
routine  of  the  antiphlogistic  treatment.     In  a  sin- 
gle puncture  of  the  capsule,  even  when  synovia 
has  escaped,  the  orifice  may  heal  by  quick  union ; 
but   when    local   inflammation    ensues,    and   runs 
such  an  acute  course  that  the  free  application  of 
leeches — twenty  to  forty  to  a  limb — do  not  quell 
the  inflammation,  but,  running  on,  we  are  led  to 
infer  that  pus  has  formed  within  the  joint,   the 
articulation    should   be   largely   opened,    and   the 
joint  thoroughly  cleansed,  whether  we  resect  the 


COMPOUND    FRACTURE    OF    THE    LEG.  367 

heads  of  the  bones  or  not.  There  is  no  longer 
any  injury  from  the  admission  of  air,  whilst  there 
is  serious  fear  of  destruction  of  the  cartilages 
should  the  collection  of  pus  be  retained.  This 
free  opening  of  the  articulation  may,  in  some 
cases,  obviate  the  necessity  for  secondary  resec- 
tions, as  excellent  results  have  been  obtained  by 
this  apparently  bold  surgery,  the  patient  saving 
his  life  and  limb,  with  an  anchylosed  joint.  The 
effect  of  this  incision  in  allaying  the  general  irri- 
tation is  said  to  be  marked. 

The  course  which  will  be  pursued  with  a  frac- 
ture of  the  bones  of  the  leg  must  depend  upon 
the  extent  of  injury  to  the  soft  parts,  and  also  the 
facilities  at  hand  for  treating  fractures.  Our  main 
object  is  always  to  save  life,  and,  if  possible,  the 
limb  also  ;  but,  in  our  too-grasping  disposition, 
we  must  be  very  guarded  how  we  jeopard  the  one 
to  save  the  other.  It  is  in  this  respect  that  mili- 
tary surgery  is  so  very  different  from  civil  prac- 
tice, as  we  are  continually  compelled  to  sacrifice 
limbs  to  expediency,  when,  under  more  favorable 
conditions,  we  would  not  hesitate  to  practice  con- 
servative surgery.  To  introduce  a  single  example: 
where  a  long  and  tedious  transportation  becomes 
necessary  after  a  battle,  it  would  be  expedient  to 
amputate   much  more   freely  than  we  would  do 


368  COMPOUND    FRACTURE    OF    THE    LEG. 

were  hospitals  in  the  immediate  neighborhood  of 
the  battle  field  where  the  wounded  could  be  treated. 
How,  for  instance,  could  we  transport  with  any 
chance  of  success  a  resected  joint,  such  as  the 
shoulder  or  a  gunshot  fractured  thigh  or  leg  ? 
Under  such  circumstances  an  amputation  would 
give  the  patient  a  much  better  chance  for  life, 
which  should  be  always  the  main  object. 

When  facilities  offer  for  attempting  the  preser- 
vation of  a  fractured  leg,  the  same  precautions  are 
taken  as  in  other  fractures,  for  removing  immedi- 
ately all  loose  or  very  movable  fragments  of  bone. 
The  limb  is  placed  in  a  fracture  box,  or  upon  the 
double  incline-plane,  and  by  the  constant  applica- 
tion of  cold  water,  whilst  we  use  those  remedies 
already  suggested  for  keeping  down  an  excessive 
reaction,  we  watch  the  march  of  the  case,  and 
meet  the  various  complications,  as  they  arise,  by 
rules  of  practice  which  have  been  already  fre- 
quently discussed.  Should  mortification  appear  in 
the  wound  a  few  days  after  the  injury,  Ave  will 
find  the  only  means  of  safety  in  early  amputation. 

Resections  of  the  ankle-joint  have  not  been 
followed  by  that  success  which  has  characterized 
operations  upon  the  larger  joints,  especially  the 
knee  and  the  elbow.  It  is  recommended  as  a  con- 
servative practice,  but  is  seldom  practiced.     When 


\ 


rules  for  amputating:.  369 

gunshot  injuries  occur  about  the  ankle,  crushing 
the  bones,  excision  offers  but  a  meagre  resource. 
Mortification  often  follows  upon  such  injuries, 
and  amputation  holds  out  stronger  inducements 
for  immediate  and  subsequent  benefit. 

We  have  often  referred  to  the  fact  that  am- 
putations will  ever  be  a  necessity  in  military 
surgery;  and,  according  to  McLeod,  had  they 
been  more  freely  practiced  in  the  Crimea,  a 
larger  number  of  lives  would  have  been  saved. 
It  was  on  that  account  that,  in  the  distribution 
of  labor,  in  field  infirmaries,  it  was  recommended 
that  the  surgeon  who  had  had  the  greatest  ex- 
perience, and  upon  whose  judgment  most  reli- 
ance could  be  placed,  should  officiate  as  exam- 
iner; and.  his  decision  should  be  carried  out  by 
those  who  may  possess  a  greater  facility  for  the 
operative  manual.  As  a  general  rule,  the  fol- 
lowing conditions  necessitate  the  loss  of  a  limb, 
viz :  When  an  entire  limb  is  carried  off  by  a 
cannon  ball,  leaving  a  ragged  stump;  or  when 
.a  limb  is  literally  crushed  up,  although  still 
attached  to  the  body,  it  will  be  necessary  to  am- 
putate to  form  a  good  stump ;  also,  if  the  prin- 
cipal vessels  and  nerves  are  torn,  even  without 
injury  to  the  bone;  or  if  the  soft  parts  are  much 


370  RULES    FOR    AMPUTATING. 

lacerated;  or  in  cases  of  extensive  destruction  of 
the  skin,  as  such  cases  offer  very  tedious  cures 
if  cicatrization  is  ever  obtained;  or  in  severe  com- 
pound fractures;  or  often  in  apparently  simple 
compound  fractures,  where  experience  teaches  us 
that  although  the  wound  appears  trifling  to-day, 
in  attempting  to  save  it  we  will  sacrifice  a  life  a 
few  days  hence.  Amputation  is  also  compul- 
sory when  mortification  of  the  limb  rapidly  fol- 
lows upon  an  injury ;  or  when,  in  compound 
fractures  or  perforated  joints,  the  profuse  dis- 
charge or  the  continued  irritation  threatens  a 
fatal  issue ;  also,  where  joints  are  crushed,  and 
where  resections  are  not  admissible;  or  where  a 
fracture  of  the  shaft  of  a  bone  extends  into  a 
joint ;  or  in  cases  where  secondary  hemorrhage 
cannot  be  controlled  by  the  ligature,  or  by  any 
other  hemostatic.  Knowing  that  in  such  cases, 
sooner  or  later,  the  limb  and  life  will  be  jeopard- 
ized, we  must  anticipate  these  troubles  by  ampu- 
tation. 

Military  surgeons  have  long  made  the  impor- 
tant division  of  amputations  into  primary  and, 
secondary  —  a  division  of  great  practical  impor- 
tance, and  which  forces  itself  upon  our  notice  by 
the  relative  mortality  following  the  two  opera- 
tions.    Amputations  for  direct  injury  are   styled 


RULES    FOR    AMPUTATING.  371 

primary;  those  required  for  cases  of  mortification, 
profuse  suppuration,  secondary  hemorrhage,  or 
for  necroses,  are  called  secondary  or  mediate,  and 
comprise  all  amputations  performed  after  the  first 
twenty-four  or  thirty-six  hours,  when  reaction  has 
set  in.  The  experience  of  every  battle  field  shows, 
that  the  mortality  following  the  amputation  of 
limbs  which  require  immediate  operation  is  always 
less  than  those  performed  some  days  after  the 
infliction  of  the  wound,  although  the  milder  cases 
were  those  retained,  and  the  most  severe  those 
selected  for  immediate  operation.  As  all  military 
surgeons  recognize  the  propriety  of  amputating 
condemned  limbs  within  twenty-four  or  thirty-six 
hours  after  injury,  before  inflammatory  reaction 
has  set  in,  the  subject  requires  no  discussion.  The 
rule  in  military  surgery  is  absolute,  viz  :  that  the 
amputating  knife  should  immediately  follow  the  con- 
demnation of  the  limb.  These  are  operations  for 
the  battle  field,  and  should  be  performed  at  the 
field  infirmary.  When  this  golden  opportunity, 
before  reaction,  is  lost,  it  can  never  be  compen- 
sated for. 

The  rule  in  performing  primary  amputations 
is,  to  operate  as  far  as  possible  from  the  trunk, 
as  every  inch  diminishes  the  risk  to  life.  This 
rule  is  so  general,  that  when  an  amputation  can 


Oil  RULES    FOR    AMPUTATING. 

be  performed  at  a  joint,  never  amputate  higher 
up;  for  instance,  if  an  amputation  cannot  be  per- 
formed upon  the  upper  part  of  the  leg,  remove 
the  limb  at  the  knee-joint  rather  than  amputate 
the  thigh.  In  secondary  amputations  it  may  not 
be  expedient  to  follow  this  rule;  necessity  or  the 
desire  to  save  life,  which  is  always  paramount, 
may  compel  us  to  amputate  at  a  distance  from 
the  injury,  as  in  cases  of  mortification.  Gangrene 
should  seldom,  however,  require  a  secondary 
amputation,  if  the  rules  for  primary  amputation 
be  followed — of  removing  at  once  all  limbs  in 
which  the  blood-vessels  and  nerves  are  exten- 
sively injured  in  connection  with  the  crushing 
of  the  bones.  When  mortification  attacks  a 
limb,  it  will  be  known  by  the  change  of  color  in 
the  skin.  When  it  occurs  in  the  leg,  which  is  its 
common  seat,  the  foot  changes  from  the  natural 
flesh  color  to  a  tallowy  or  mottled  white ;  the 
tissues  in  a  measure  liquify,  are  cold,  and  be- 
come offensive — breaking  up  into  more  or  less 
extended  sloughs,  saturated  with  an  ichorous 
fluid.  This  gangrenous  condition  may  stop  at 
the  ankle,  either  above  or  below  it,  depending 
upon  the  seat  of  injury  ;  or  it  may  creep  up  to 
the  knee,  where  it  equally  shows  a  disposition 
to   limit  its  extension.     When   the   ankle   limits 


RULES    FOR    AMPUTATING.  373 

the  mortification,  we  amputate  below  the  knee ; 
when  otherwise,  above  it.  These  cases  are 
usually  unsatisfactory,  as  a  general  poisoning  is 
soon  effected,  and  the  stump  wherever  made,  is 
attacked  in  a  few  days,  as  if  by  a  continuation 
of  the  same  gangrene. 

In  mortification  of  the  stump,  unless  it  be  in 
the  vicinity  of  the  ankle-joint,  a  second  amputa- 
tion is  not  admissible.  By  the  local  use  of  pure 
nitric  acid  to  the  mortified  surface,  or  the  concen- 
trated Labarraques'  chloride  of  soda  or  pyroligne- 
ous  acid,  we  strive  to  limit  the  extent  of  the 
slough ;  whilst,  with  carbonate  of  ammonia,  qui- 
nine, brandy,  and  strong  food,  we  support  the 
system  until  some  improvement  makes  its  appear- 
ance in  the  stump.  When  all  the  sloughs  have 
been  eliminated  and  the  stump  has  commenced  to 
cicatrize,  will  be  time  enough  to  remodel  the  old 
amputation,  by  cutting  off  the  protruding  bone, 
which  is  always  better  than  performing  a  second 
amputation. 

Having  condemned  a  limb,  we  should  wait 
until  the  nervous  shock — from  which  most  of 
the  wounded  suffer — subsides,  and  then  give  chlo- 
roform. Should  we  not  have  the  time  for  its 
proper  inhalation,  we  may  inject  a  half  grain  or 
more   of   morphine    under    the    skin,    which    will 


874  RULES    FOR   AMPUTATING. 

produce  a  rapid  blunting  of  nervous  sensibilities ; 
and  in  rive  minutes,  or  even  in  less  time,  the 
patient  will  be  in  a  fit  condition  to  stand  the 
operation,  with  the  least  degree  of  constitutional 
shock. 

In  the  performance  of  all  serious  operations, 
when  possible,  there  should  be  three  assistants. 
One  aid  gives  the  chloroform ;  a  second  com- 
presses the  main  artery,  which  is  much  better 
than  using  the  tourniquet — an  instrument  which 
is  now  in  a  great  measure  discarded  from  prac- 
tice ;  and  a  third  holds  the  limb  and  supports 
the  flap  during  the  section.  The  aid  who  ad- 
ministered the  chloroform  during  the  incisions, 
can  assist  in  ligating  the  arteries.  Military  sur- 
geons prefer  the  circular  operation  to  the  Hap, 
which  they  only  use  in  the  exceptional  cases. 
With  the  circular  stump,  covered  only  by  skin, 
there  is  less  soft  tissue  to  suppurate  and  slough, 
and  a  much  more  rapid  cicatrization  is  effected. 
Experience,  which  has  long  recognized  the  utility 
of  the  circular  operation  for  the  leg,  has  now 
generalized  it  as  the  most  useful  amputation  for 
the  thigh  or  arm. 

Having  assigned  the  aids  their  posts,  and  seen- 
that  all  the  necessary  instruments  which  may 
be    needed  are    at    hand — for    a    surgeon    should 


RULES    FOR    AMPUTATING.  375 

never  commence  an  operation  until  he  has  satis- 
fied himself  on  this  score — the  surgeon  removes 
the  limh,  ligates  the  vessels,  and  when  all  ooz- 
ing has  ceased,  secures  the  stump  by  points  of 
suture  placed  at  intervals  of  an  inch  or  a  little 
less  along  the  entire  line  of  wound. 

In  dividing  the  skin,  the  surgeon  cannot  be  too 
careful  to  leave  an  ample  flap  to  cover  the  heads 
of  the  bones.  This  is  the  first  and  most  impor- 
tant rule  in  amputation.  You  cannot  well 
leave  too  much  skin,  and  can  very  easily  com- 
mit the  opposite  error.  The  surplus  of  skin  will 
be  absorbed ;  a  deficiency  can  in  no  way  be  sup- 
plied. The  rule  is,  to  have  the  flaps  so  ample 
that  no  tension  be  necessary  in  closing  the  wound. 
One  of  the  most  constant  as  well  as  one  of  the 
most  frightful  exhibitions  in  military  hospitals, 
where  the  surgeons  have  not  yet  gained  expe- 
rience, is  the  protrusion  of  the  bones  from  the 
stumps  of  amputated  limbs,  necessitating  a  sec- 
ond operation,  should  the  patient  survive  the 
first.  A  little  care  will  obviate  all  of  this  trouble, 
and  save  the  surgeon  much  mortification.  Any 
omission  in  this  respect  must  be  corrected  before 
the  stump  is  dressed;  and  if  the  bone  is  found 
so  long  that  the  skin  cannot  be  made  to  cover  it 
without  traction,  remove  a  section  of  bone  with 


876  DRESSING    OF    STUMPS. 

the  saw,  and  not  attempt,  through  want  of  hon 
esty,  to  conceal  a  badly-performed  operation,  and 
make  the  innocent  patient  the  victim  of  our  mis- 
placed pride.  In  ligating  the  vessels,  tie  every 
one  which  bleeds  or  is  likely  to  bleed.  It  is 
not  derogatory  for  a  surgeon  to  apply  ten, 
fifteen,  or  even  twenty  ligatures  to  a  stump ;  it 
shows  that  he  understands  his  profession ;  expe- 
rience has  taught  him  the  great  trouble  and  an- 
noyance of  reopening  a  stump  to  find  a  bleeding 
vessel,  when  he  has  but  little  time  to  attend  to 
the  urgent  demands  of  the  wounded.  The  rule 
is,  neglect  no  small  artery. 

As  adhesive  straps  for  supporting  and  sustain- 
ing the  flaps  are  antagonistic  to  water  dressings, 
they  are  useless  in  amputations,  and  are  not 
used,  except  a  small  patch  to  secure  the  liga- 
tures upon  the  limb  at  one  angle  of  the  wound. 
A  single  layer  of  wet  cloth  is  applied  to  the 
stump;  this  in  turn  is  covered  by  a  piece  of 
waxed  cloth,  to  keep  in  the  moisture,  and  either 
an  ice  bladder  or  water  bj~  irrigation  is  contin- 
uously applied  over  this  outer  cloth.  The  case 
should  now  be  looked  upon  as  a  wound,  and 
should  be  treated  accordingly.  The  course  la-id 
down  for  wounds  is  here  strictly  applicable,  and 
should    be  closelv  followed.     Sutures  are   recom- 


DRESSING    OP    STUMPS.  377 

mended  in  all  operations,  as  they  keep  the  flaps 
in  apposition,  not  being  influenced  by  the  water 
dressings ;  they  also  obviate  much  after-dress- 
ing. The  use  of  sutures  does  away  with  adhe- 
sive straps,  which,  when  water  dressings  are 
used,  are  always  inconvenient  and  often  useless. 
In  certain  cases  of  amputation,  as  in  the  circu- 
lar, where  the  skin  alone  forms  the  flap,  the 
dressing  may  be  changed,  as  follows:  After  ap- 
plying sutures  to  the  entire  length  of  the  wound, 
draw  the  intervening  spaces  accurately  together 
by  means  of  strips  of  isinglass  plaster,  and  cover, 
also,  the  length  of  the  wound  with  a  folded  strip, 
only  leaving  uncovered  the  angle  where  the  liga- 
tures escape  and  where  drainage  from  within  is 
permitted.  The  object  of  the  dressing  is  to  con- 
vert the  wound  into  a  subcutaneous  one,  exclud- 
ing the  air  and  hastening  union.  To  the  stump 
no  other  dressing  is  applied,  the  wound  being 
exposed.  ISTo  water  dressing  is  to  be  used,  and 
the  stump  is  left  unmolested,  except  cleansing 
the  effects  of  drainage;  when,  at  the  expiration 
of  a  week,  the  removal  of  the  straps  will  com- 
plete cicatrization  along  the  line  of  incision.  In 
healthy  patients  and  in  a  pure  atmosphere,  a 
rapid  healing  of  stumps  may  in  this  way  be  ob- 
tained. The  isinglass  plaster  will  alone  answer — 
32 


37$  DRESSING    OF    STUMPS. 

the  diachylon  being  too  irritating  and  not  suf- 
ficiently pliant  to  seal  hermetically  the  wound. 
We  find  but  little  use  for  ointments  in  dress- 
ing stumps,  the  wet  cloth  being  much  simpler, 
not  irritating,  and  therefore  more  efficient. 

During  the  treatment  of  all  wounds  in  milita- 
ry hospitals,  previous  want  and  exposure,  which 
belongs  to  every  army,  however  well  organized, 
will  show  their  influence  ;  and  if  the  plan  of  abste- 
mious or  antiphlogistic  diet  be  adopted  for  those 
operated  upon,  from  misguided  views  of  the  pa- 
thology of  inflammation,  the  mortality  will  be 
heavy.  Liberal  feeding  tells  in  the  after-treat- 
ment of  amputations ;  and  the  great  difference 
in  the  surgical  statistics  of  the  French  and  Eng- 
lish depends  more  perhaps  upon  the  diet  in 
their  hospital  practice  than  upon  any  one  other 
cause.  Tisanes  cannot  support  a  person  in  or- 
dinary health,  and  certainly  cannot  support  him 
under  the  additional  drain  of  an  exhausting  sup- 
puration. If  patients  are  placed  under  identical- 
ly similar  conditions,  the  successful  treatment  of 
amputations  will  be  found  to  lean  to  the  side  of 
those  who  are  the  most  liberally  supported.  Slops 
are  out  of  place  in  a  surgical  hospital,  and  good 
cooking  will  be  found  as  useful  as  good  nurs- 
ing.    Let   nature   be   our  guide.     For   the    first 


CHLOROFORM    INDISPENSABLE.  379 

one  or  two  clays  after  a  serious  operation  there 
is  but  little  disposition  to  eat.  Under  such  con- 
ditions, I  would  not  advise  food  to  be  forced ; 
but  as  soon  as  the  patient  expresses  a  desire  to 
eat,  foster  his  appetite  with  good,  strong,  nour- 
ishing, easily-digested  food,  and  let  his  supply 
be  liberal.  Any  attempt  at  starvation  will  be 
highly  injurious. 

If  the  patient  escapes  the  ordinary  diseases 
incident  to  hospitals,  viz:  erysipelas,  gangrene, 
pyaemia,  etc.,  we  must  be  extremely  careful  of 
him  about  the  tenth  or  twelfth  day.  When  the 
ligatures  are  escaping  from  the  arteries,  absolute 
rest  should  be  insisted  upon,  and  the  patient 
should  not  be  allowed  to  exert  himself  in  any 
way  until  this  fear  of  secondary  hemorrhage  is 
passed.  We  have  elsewhere  stated  how  this  com- 
plication is  to  be  met. 

Whenever  operations  are  to  be  performed  in 
military  surgery,  chloroform  should  be  adminis- 
tered. It  is  a  remedy  which  the  surgeon  should 
never  be  without,  and  which. might  be  used  on  all 
occasions  with  advantage ;  whether  for  operations 
or  for  dressing  painful  wounds,  as  in  the  cleans- 
ing of  compound  fractures.  The  effects  of  chlo- 
roform are  wonderful  in  mitigating  the  suffering 
of  the  wounded,  and  it  is  often    instrumental  in 


380  CHLOROFORM    INDISPENSABLE. 

the  cure  of  wounds,  from  the  rest  and  tranquility 
of  mind   which    follows    its   inhalation.      It   also 
prevents  excessive  reaction  in  the  paroxysms  of 
traumatic  fever.     During  the  performance  of  capi- 
tal operations  on  the  hattle  field,  death  sometimes 
ensues    from    nervous    exhaustion,    produced   by 
excess  of  suffering;  the  use  of  chloroform  relieves 
the  patient  at  least  from  this  risk.     Those  brought 
up  in  the  older  school,  before  the  days  of  anaes- 
thetics, in  refusing  all  innovations,  still  insist  on 
decrying  the  dangers  of  this  potent  remed}T,  and 
moralize  upon  the  duty  of  suffering,  as  submitting 
to  an  express  infliction  from  on  high.     Although 
the   French    surgeons   in   the   Crimea  report  the 
successful   administration  of  chloroform  to  thirty 
thousand  wounded,  without  a  single  accident,  and 
McLeod  refers  to  its  great  utility  in  the  Crimea, 
where  it  was    administered   to   twenty   thousand 
soldiers,  and  more  than  realized  the  most  enthu- 
siastic anticipations  of  the  medical  staffs,  still  we 
find  some  of  the  older  school,  who  are  in  author- 
ity, sneer  at  its  pretensions  and  magnify  its  dan- 
gers.    Dr.  Hall,  who  is  at  the  head  of  the  English 
medical   staff,  in  giving  instructions  to  the  sur- 
geons upon  entering  active  service  in  the  Crimea, 
cautioned    them    against    the    administration    of 
chloroform   in   the   severe    shock  of  serious  gun- 


CHLOROFORM    INDISPENSABLE.  381 

shot  wounds,  as  lie  thinks  that  few  will  survive 
where  it  is  used.     But  as  he   finds   public  opin- 
ion, which  he  calls  mistaken  philanthropy,  against 
him,    he    disparages    chloroform,    and    lauds    the 
lusty  bawling  of   the   wounded   from   the    smart 
of  the  knife,  as  a  powerful  stimulant  which  has 
roused  many  a  sinking  man   from   his  apathetic 
state.     Some  of  the  older   surgeons  characterize 
the  cries  of  the  patient  as  music  to  the  ear,  and 
speak   of  it  as  an  advantage  to  be  courted,  and 
not    to    be    suppressed.      Notwithstanding    such 
advice,    the  universal   use   of  chloroform   in   the 
Crimea  and    later  in    Italy,  is  a  complete   vindi- 
cation of  the  utility  of  the  remedy,  and  proof  of 
its  necessity:  and  now  we  consider  it  an  essen- 
tial  among  army    supplies.      For  ourselves,  who 
place  unlimited  confidence  in  its  judicious  admin- 
istration, and,  with  a  large   experience,  we   have 
never  had  the  slightest  cause  to  doubt  its  advanta- 
ges under  every  circumstance.     We  hope  that  the 
humanizing  tendencies  of  the  age,  in  introducing 
this  invaluable  comfort,  has  banished  that  dread 
of  being  cut  as  an  item  to  be  considered  when 
operations   are    necessary;    and    we   hope   to   see 
anaesthetics  used  as  liberally  in  allaying  the  pain 
of  surgical  affections  as  cold  water  is  now  used 
for  keeping  down  inflammation.      We  do  not  hesi- 


382  HOW    TO    GIVE    CHLOROFORM. 

fate  to  sag,  that  it  should  be  given  to  every  patient 
requiring  a  serious  or  painful  operation.  We  may 
hear  now  and  then  of  an  accident  from  its  admin- 
istration, but  who  can  tell  us  of  the  immense 
number  who  would  have  sunk  from  operations, 
had  it  not  been  administered? 

In  its  administration  we  must  use  the  following 
precautions:  The  best  apparatus  is  a  folded  cloth 
in  a  form  of  a  cone,  in  the  apex  of  which  a  small 
piece  of  sponge  is  placed.  This  is  first  held  at 
some  distance  from  the  nose  and  mouth  of  the  pa- 
tient, so  that  the  first  inhalation  may  be  well  dilu- 
ted with  air.  As  the  exhilarating  stage  is  reached, 
the  cloth  should  be  approached  to  the  nose,  so 
that  a  more  concentrated  ether  may  be  inhaled, 
which  will  rapidly  produce  the  desired  insensi- 
bility. Noisy  breathing  is  the  sign  that  the  anaes- 
thetic effect  is  produced,  when  the  inhalation 
should  be  suspended  and  the  operation  com- 
menced. Unless  the  operation  is  very  tedious,  do 
not  renew  the  inhalation. 

Ingenious  inhalors  are  more  or  less  complica- 
ted, and  are  on  that  account  more  or  less  ineffi- 
cient. The  great  perfection  of  the  above-men- 
tioned apparatus  is  its  simplicity.  Finding  that 
much  chloroform  is  wasted  by  evaporation  from 
the  handkerchief,  I  have  for  some  years  used  a 


HOW    TO    GIVE    CHLOROFORM.  383 

common  funnel  as  my  inhalor,  which,  protects 
the  hands  of  the  person  administering  the  chlo- 
roform, and  prevents  the  loss  from  general  evapo- 
ration. If  a  piece  of  heavy  wire  or  a  small  bar 
of  tin  be  attached  across  the  interior  of  the  fun- 
nel, about  half-way  toward  its  throat,  the  sponge 
containing  the  chloroform  can  be  supported  be- 
tween this  bar  and  the  side  of  the  funnel,  leaving 
a  space  on  one  side  for  the  air  to  rush  over  the 
surface  of  the  sponge  as  it  comes  through  the 
elongated  end  of  the  apparatus,  when  the  air 
loaded  with  ether  is  inhaled.  The  funnel  should 
be  large  enough  to  cover  the  lower  half  of  the 
face,  including  nose  and  mouth,  and  the  sponge 
should  not  come  within  two  inches  of  the  face, 
for  should  it  touch  the  skin  it  would  blister 
it.  The  eyes,  being  excluded  from  the  appa- 
ratus, are  not  anno}Ted  by  the  evaporation  of 
chloroform.  As  the  funnel  does  not  fit  accu- 
rately to  the  lower  outline  of  the  face,  there 
will  be  ample  spaces  on  either  side  of  the 
chin  to  admit  air  for  diluting  the  vapor.  Be- 
sides a  great  saving  of  chloroform,  which  is  no 
small  recommendation,  the  use  of  this  instru- 
ment obviates  the  fear  of  suffocation,  which  is 
always  present  to  my  mind  when  I  see  chloro- 
form  carelessly   administered.     When    the   cloth 


384  HOW    TO    GIVE    CHLOROFORM. 

is  used,  should  the  patient  struggle — a  ^ery  com- 
mon occurrence — or  should  the  assistant  admin- 
istering the  anaesthetic  he  at  all  interested  in 
the  operation,  the  cloth  is  thrust  down  upon  the 
face  of  the  patient,  respiration  is  impeded,  and 
suffocation  is  imminent.  Suppose  the  patient 
has  already  been  influenced  to  such  an  extent 
that  he  has  lost  the  voluntary  control  of  his 
muscles,  and  cannot  pull  away  the  cloth,  he 
is  in  a  very  dangerous  condition,  and  the  con- 
tinued thoughtlessness  of  the  assistant  might 
suffocate  him.  I  can  readil}r  understand,  in  this 
way,  why  deaths  should  sometimes  occur  from 
the  carelessness  of  administration,  and  am  only 
surprised  that  it  occurs  so  seldom.  Were  we  as 
careless  in  the  use  of  other  potent  remedies  as 
we  are  of  chloroform,  cases  of  poisoning  would 
be  largely  increased.  In  times  of  hurry,  confu- 
sion and  excitement,  as  after  a  battle,  we  can- 
not surround  the  safety  and  well-being  of  the 
wounded  with  too  many  guards  for  their  protec- 
tion. 


APPENDIX. 


33 


Appendix  ISTo.  1. 


REGULATIONS 

FOR 

THE  MEDICAL   DEPARTMENT 

OF  THE 

CONFEDERATE   STATES. 


1 .  .  .  .The  Surgeon-General  is  charged  with  the  administrative 
details  of  the  medical  department,  the  government  of  hospitals, 
the  regulation  of  the  duties  of  surgeons  and  assistant  surgeons, 
and  the  appointment  of  acting  medical  officers,  when  needed, 
for  local  or  detached  service.  He  will  issue  orders  and  instruc- 
tions relating  to  the  professional  duties  of  medical  officers ;  and 
all  communications  from  them,  which  require  his  action,  will  be 
made  directly  to  him. 

2 .  .  .  .  The  senior  medical  officer  on  duty  with  an  army  corps 
in  the  field,  is  the  Medical  Director  of  that  army,  and  he  will 
have  the  general  control  of  the  medical  officers. 

3 .  .  .  .  The  medical  director  will  inspect  the  hospitals  under  his 
control,  and  see  that  the  rules  and  regulations  with  regard  to 
them  and  the  duties  of  the  surgeons  and  assistant  surgeons,  are 
enforced. 

4 .  .  .  . He  will  examine  the  ease  books,  prescription  and  diet 
books,  and  ascertain  the  nature  of  diseases  which  may  have  pre- 
vailed, and  their  probable  causes;  recommend  the  best  method 
of  prevention,  and   also  make  such  suggestions  relative  to  the 


888  APPENDIX. 

situation,  construction  and  economy  of  the  hospitals,  as  may 
appear  necessary  for  the  benefit  and  comfort  of  the  sick  and  the 
good  of  the  service. 

5 .  . .  .  He  will  require  from  the  medical  officers  of  the  com- 
mand monthly  reports  of  the  sick  and  wounded  (Form  1),  and 
from  the  data  furnished  by  them,  will  make  to  the  Surgeon- 
General  a  consolidated  monthly  report  of  the  sick  and  wounded. 

6.  .  .  .He  will  make  to  the  Surgeon-General  a  monthly  return 
(Form  2)  of  the  medical  officers  of  the  command. 

7.  .  .  .The  Meilical  Purveyors  will,  under  the  direction  of  the 
Surgeon-General,  purchase  all  medical  and  hospital  supplies 
required  for  the  medical  department  of  the  army. 

8 .  . .  .  Medical  purveyors  will  make  to  the  Surgeon-General, 
at  the  end  of  each  fiscal  quarter,  returns  in  duplicate  (Form  3) 
of  medical  supplies  received,  issued  and  remaining  on  hand, 
stating  to  whom,  or  from  whom,  and  when  and  where  issued  or 
received.  Other  medical  officers  in  charge  of  medical  supplies 
will  make  similar  returns  semi-annually,  on  the  30th  of  June 
and  the  31st  of  December:  and  all  medical  officers  will  make 
them  when  relieved  from  the  duty  to  which  their  returns  relate. 
The  returns  will  show  the  condition  of  the  stores,  and  particu- 
larly of  the  instruments,  bedding  and  furniture.  Medical  pur- 
veyors will  furnish  abstracts  of  receipts  and  issues  with  their 
returns  (Form  4). 

9 .  .  .  .  Medical  disbursing  officers  will,  at  the  end  of  each  fiscal 
quarter,  render  to  the  Surgeon-General,  in  duplicate,  a  quarterly 
account  current  of  moneys  received  and  expended,  with  the 
proper  vouchers  for  the  payments,  and  certificates  that  the  ser- 
vices have  been  rendered  and  the  supplies  purchased  and  re- 
ceived for  the  medical  service,  and  transmit  to  him  an  estimate 
of  the  funds  required  for  the  next  quarter. 

10.  ..  .The  medical  supplies  for  the  army  are  prescribed  in 
the  Standard  Supply  Tables  for  Hospitals  or  Field  Service. 

11 ...  .Medical  and  hospital  supplies  will  be  obtained  by 
making  requisitions,  in  duplicate  (Form  5),  on  the  Surgeon- 
General,  forwarding  them  through  the  medical  director  of  the 
command.     If  an  army  be  in  the  field,  and  there  be  a  medical 


APPENDIX.  389 

purveyor  in  charge  of  supplies,  requisitions  will  be  made  on  him, 
after  receiving  the  approval  of  the  medical  director. 

12.  . .  .When  it  is  necessary  to  purchase  medical  supplies,  and 
recourse  cannot  be  had  to  a  medical  disbursing  officer,  they  may 
be  procured  by  the  quartermaster  on  a  special  requisition 
(Form  6)  and  account  (Form  7). 

13.  .  .  .In  every  case  of  special  requisition,  a  duplicate  of  the 
requisition  shall,  at  the  same  time,  be  transmitted  to  the  Surgeon- 
General,  for  his  information. 

14.  .  .  .An  officer  transferring  medical  supplies,  will  furnish  a 
certified  invoice  to  the  officer  who  is  to  receive  them,  and  trans- 
mit a  duplicate  of  it  to  the  Surgeon-General.  The  receiving 
officer  will  transmit  duplicate  receipts  to  the  Surgeon-General, 
with  a  report  of  the  quality  and  condition  of  the  supplies,  and 
report  the  same  to  the  issuing  officer.  A  medical  officer  who 
turns  over  medical  supplies  to  a  quartermaster  for  storage  or 
transportation,  will  forward  to  the  Surgeon-General,  with  the 
invoice,  the  quartermaster's  receipts  for  the  packages. 

15.  . .  .Medical  officers  will  take  up  and  account  for  all  medi- 
cal supplies  of  the  army  that  come  into  their  possession,  and 
report,  when  they  know  it,  to  whose  account  they  are  to  be 
credited. 

16.  . .  .In  all  official  lists  of  medical  supplies,  the  articles  will 
be  entered  in  the  order  of  the.  supply  table. 

17....  The  senior  medical  officer  of  a  hospital  will  distribute 
the  patients,  according  to  convenience  and  the  nature  of  their 
complaints,  into  wards  or  divisions,  under  the  particular  charge 
of  the  several  assistant  surgeons,  and  will  visit  them  himself 
each  day  as  frequently  as  the  state  of  the  sick  may  require, 
accompanied  by  the  assistant,  steward  and  nurse. 

18.... His  prescriptions  of  medicine  and  diet  are  written 
down  at  once  in  the  proper  register,  with  the  name  of  the 
patient  and  the  number  of  his  bed ;  the  assistants  fill  up  the 
diet  table  for  the  day,  and  direct  the  administration  of  the  pre- 
scribed medicines.  He  will  detail  an  assistant  surgeon  to  remain 
at  the  hospital  day  and  night,  when  the  state  of  the  sick  re- 
quires it. 

19.  .  .  .In  distributing  the  duties  of  his  assistants,  he  will  ordi- 


.'j90  appendix. 

narily  require  the  aid  of  one  in  the  care  and  preparation  of  the 
hospital  reports,  registers  and  records,  the  rolls  and  descriptive 
lists;  and  of  another,  in  the  charge  of  the  dispensary,  instru- 
ments, medicines,  hospital  expenditures,  and  the  preparation  of 
the  requisitions  and  annual  returns. 

20 ...  .  He  will  enforce  the  proper  hospital  regulations  to 
promote  health  and  prevent  contagion,  by  ventilated  and  not 
crowded  rooms,  scrupulous  cleanliness,  frequent  changes  of  bed- 
ding and  linen,  occasional  refilling  of  the  bed  sacks  and  pillow 
ticks  with  fresh  straw,  regularity  in  meals,  attention  to  cooking, 
etc. 

21.  .  .  .He  will  require  the  steward  to  take  due  care  of  the 
hospital  stores  and  supplies;  to  enter  in. a  book,  daily  (Form  8), 
the  issues  to  the  wardmasters,  cooks  and  nurses ;  to  prepare  the 
provision  returns,  and  receive  and  distribute  the  rations. 

22.  . .  .He  will  require  the  wardmaster  to  take  charge  of  the 
effects  of  the  patients ;  to  register  them  in  a  book  (Form  9)  ;  to 
have  them  numbered  and  labelled  with  the  patient's  name,  rank 
and  company  ;  to  receive  from  the  steward  the  furniture,  bed- 
ding, cooking  utensils,  etc.,  for  use,  and  keep  a  record  of  them 
(Form  10),  and  how  distributed  to  the  wards  and  kitchens,  and 
once  a  week  to  take  an  inventory  of  the  articles  in  use,  and 
report  to  him  any  loss  or  damage  to  them,  and  to  return  to  the 
steward  such  as  are  not  required  for  use. 

23.  . .  .Assistant  surgeons  will  obey  the  orders  of  their  senior 
surgeon  ;  see  that  subordinate  officers  do  their  duty,  and  aid  in 
enforcing  the  regulations  of  the  hospital. 

24 ...  .  The  cooks  and  nurses  are  under  the  orders  of  the 
steward.  He  is  responsible  for  the  cleanliness  of  the  wards  and 
kitchens,  patients  and  attendants,  and  all  articles  in  use.  He 
will  ascertain  who  are  present  at  sunrise  and  sunset,  and  tattoo, 
and  report  absentees. 

25 ....  At  surgeon's  call  the  sick  then  in  the  companies  will 
be  conducted  to  the  hospital  by  the  first  sergeants,  who  will  each 
hand  to  the  surgeon,  in  his  company  book,  a  list  of  all  the  sick 
of  the  company,  on  which  the  surgeon  shall  state  who  are  to 
remain  or  go  into  hospital ;  who  are  to  return  to  quarters  as 
sick  or  convalescent ;  what  duties  the  convalescents  in  quarters 


APPENDIX.  391 

are  capable  of;  what  cases  are  feigned;  and  any  other  informa- 
tion in  regard  to  the  sick  of  the  company  he  may  have  to  com- 
municate to  the  company  commander. 

2G  .  .  .  .  Soldiers  in  hospital,  patients  or  attendants,  'except 
stewards,  shall  be  mustered  on  the  rolls  of  their  company,  if  it 
be  present  at  the  post. 

27....  When  a  soldier  in  hospital  is  detached  from  his  com- 
pany so  as  not  to  be  mustered  with  it  for  pay,  his  company  com- 
mander shall  certify  and  send  to  the  hospital  his  descriptive  list, 
and  account  of  pay  and  clothing,  containing  all  necessary  infor- 
mation relating  to  his  accounts  with  the  Government,  on 
which  the  surgeon  shall  enter  all  payments,  stoppages,  and  issues 
of  clothing  to  him  in  hospital.  When  he  leaves  the  hospital,  the 
medical  officer  shall  certify  and  remit  his  descriptive  list,  show- 
ing the  state  of  his  accounts.  If  he  is  discharged  from  the  ser- 
vice in  hospital,  the  surgeon  shall  make  out  his  final  statements 
for  pay  and  clothing.  If  he  dies  in  hospital,  the  surgeon  shall 
take  charge  of  his  effects,  and  make  the  reports  required  in  the 
general  regulations  concerning  soldiers  who  die  absent  from 
their  companies. 

28 ....  Patients  in  hospitals  are,  if  possible,  to  leave  their 
arms  and  accoutrements  with  their  companies,  and  in  no  case  to 
take  ammunition  into  the  hospital. 

29.... When  a  patient  is  transferred  from  one  hospital  to 
another,  the  medical  officer  shall  send  with  him  an  account  of 
his  case  and  the  treatment. 

30 ...  .  The  regulations  for  the  service  of  hospitals  apply,  as 
far  as  practicable,  to  the  medical  service  in  the  field. 

31.  . .  .The  senior  medical  officer  of  each  hospital,  post,  regi- 
ment or  detachment,  will  keep  the  following  records,  and  deliver 
them  "to  his  successor:  A  register  of  patients  (Form  11)  ;  a  pre- 
scription and  diet  book  (Form  12)  ;  a  case  book;  copies  of  his 
requisitions,  annual  returns,  and  reports  of  sick  and  wounded ; 
and  an  order  and  letter  book  ;  in  which  will  be  transcribed  all 
orders  and  letters  relating  to  his  duties. 

32.  .  .  .He  will  make  the  muster  and  pay  rolls  of  the  hospital 
steward  and  matrons,  and  of  all  soldiers  in  hospital,  sick  or  on 
duty,  detached  from   their  companies,   on  the  forms  furnished 


392  APPENDIX. 

from  the  Adjutant-General's  office,  and  according  to  the  direc- 
tions expressed  on  them. 

33.  . .  .The  extra  pay  allowed  to  soldiers  acting  as  cooks  and 
nurses  in  hospitals,  will  be  paid  by  the  pay  department.  Such 
extra  services  will  be  noted  on  the  hospital  muster  rolls,  and  for 
the  sums  thus  expended  the  pay  department  will  be  reimbursed 
by  the  medical  department. 

34 ...  .  The  senior  medical  officer  will  select  the  cooks,  nurses 
and  matrons,  with  the  approval  of  the  commanding  officer. 
Cooks  and  nurses  will  be  taken  from  the  privates,  and  will  be 
exempt  from  other  duty,  but  shall  attend  the  parades  for  muster 
and  weekly  inspection  of  their  companies  at  the  post,  unless 
specially  excused  by  the  commanding  officer. 

35 ...  ,  Ordinarily,  hospital  attendants  are  allowed  as  follows  : 
To  a  general  hospital,  one  steward,  one  nurse  as  wardmaster, 
one  nurse  to  ten  patients,  one  matron  to  twenty,  and  one  cook 
to  thirty ;  to  a  hospital,  where  the  command  exceeds  five  compa- 
nies, one  steward  and  wardmaster,  one  cook,  two  matrons,  and 
four  nurses;  to  a  post  or  garrison  of  one  company,  one  steward 
and  wardmaster,  one  nurse,  one  cook,  and  one  matron ;  and  for 
every  two  companies  more,  one  nurse;  at  arsenals,  where  the 
number  of  enlisted  men  is  not  less  than  fourteen,  one  matron 
is  allowed.  The  allowance  of  hospital  attendants  for  a  regi- 
ment in  the  field  will  be,  for  one  company,  one  steward,  one 
nurse  and  one  cook;  for  each  additional  company,  one  nurse; 
and  for  command  of  over  five  companies,  one  additional  cook. 

36.  . .  .Medical  officers,  where  on  duty,  will  attend  the  officers 
and  enlisted  men,  and  the  servants  and  laundresses  authorized 
by  law ;  and  at  stations  where  other  medical  attendance  cannot 
be  procured,  and  on  marches,  the  hired  men  of  the  army. 
Medicines  will  be  dispensed  to  the  families  of  officers  and 
soldiers,  and  to  all  persons  entitled  to  medical  attendance; 
hospital  stores  to  enlisted  men. 

3  7  .  .  .  .  Medical  officers,  in  giving  certificates  of  disability 
(Form  13),  are  to  take  particular  care  in  all  cases  that  have 
not  been  under  their  charge ;  and  especially  in  epilepsy,  convul- 
sions, chronic  rheumatism,  derangement  of  the  urinary  organs, 
ophthalmia,  ulcers,  or  any  obscure  disease,  liable  to  be  feigned 


APPENDIX.  ;593 

or  purposely  produced ;  and  in  no  case  shall  such  certificate  be 
given  until  after  sufficient  time  and  examination  to  detect  any 
attempt  at  deception. 

38 ....  In  passing  a  recruit,  the  medical  officer  is  to  examine 
him  stripped;  to  see  that  he  has  free  use  of  all  of  his  limbs ;  that 
his  chest  is  ample ;  that  his  hearing,  vision  and  speech  are 
perfect ;  that  he  has  no  tumors,  or  ulcerated  or  extensively 
cicatrized  legs  ;  no  rupture,  or  chronic  cutaneous  affection  ;  that 
he  has  not  received  any  contusion  or  wound  of  the  head  that 
may  impair  his  faculties;  that  he  is  not  a  drunkard;  is  not  sub- 
ject to  convulsions,  and  has  no  infectious  disorder,  nor  any  other 
that  may  unfit  him  for  military  service. 

39.... As  soon  as  a  recruit  joins  any  regiment  or  station, 
he  shall  be  examined  by  the  medical  officer,  and  vaccinated 
when  it  is  required. 

40.  ..  .Medical  officers  attending  recruiting  rendezvous,  will 
keep  a  record  (Form  18)  of  all  the  recruits  examined  by  them. 
Books  for  this  purpose  will  be  procured  by  application  to  the 
Surgeon-General,  to  whom  they  will  be  returned  when  filled. 

41.  . .  .The  senior  medical  officer  of  each  hospital,  post,  regi- 
ment or  detachment,  will  make  monthly  to  the  medical  director, 
and  quarterly  to  the  Surgeon-General,  a  report  of  sick  and 
wounded,  and  of  deaths,  and  of  certificates  for  discharge  for 
disability  (Form  1). 

42.  .  .  .After  surgeon's  call,  he  will  make  a  morning  report  of 
the  sick  to  the  commanding  officer  (Form  14). 

43.  . .  .Every  medical  officer  will  report  to  the  Surgeon-Gen- 
eral and  to  the  medical  director  the  date  when  he  arrives  at  a 
station,  or  when  he  leaves  it,  and  his  orders  in  the  case,  and  at 
the  end  of  each  month,  whenever  not  at  his  station,  whether  on 
service  or  on  leave  of  absence ;  and  when  on  leave  of  absence, 
his  post-office  address  for  the  next  month.  They  will  also 
acknowledge  the  receipt  of  all  orders. 

44.... When  medical  attendance  is  required  by  officers  or 
enlisted  men  on  service,  or  for  the  authorized  servants  of  such 
officers,  and  the  attendance  of  a  medical  officer  cannot  be  had, 
the  officer,  or  if  there  be  no  officer,  then  the  enlisted  man,  may 
employ  a  private  physician,  and  a  just  account  therefor  will  be 
paid  by  the  medical  bureau. 


394  APPENDIX. 

45 ...  .  The  account  will  set  out  the  name  of  the  patient,  the 
date  of  and  charge  for  each  visit,  and  for  medicines.  The 
physician  will  make  a  certificate  to  the  account  in  case  of  an 
officer,  or  affidavit  in  case  of  an  enlisted  man,  that  the  account 
is  correct,  and  the  charges  are  the  customary  charges  of  the 
place. 

4G....The  officer  will  make  his  certificate,  or  the  enlisted 
man  his  affidavit,  to  the  correctness  of  the  account,  that  he  was 
on  service  at  the  place,  and  stating  the  circumstances  prevent- 
ing him  from  receiving  the  services  of  a  medical  officer. 

47.  . .  .When  the  charge  is  against  an  officer,  he  will  pay  the 
account  if  practicable,  and  transmit  it  to  the  medical  bureau  for 
reimbursement.  In  all  other  cases,  the  account  will  be  trans- 
mitted to  the  medical  bureau  for  settlement. 

48 ....  If  the  charge  is  against  a  deceased  officer  or  enlisted 
man,  the  physician  will  make  the  affidavit,  before  required,  to 
the  account,  and  that  he  has  been  paid  no  part  of  it. 

49.... No  charges  for  consultation  fees  will  be  paid  by  the 
medical  bureau;  nor  will  any  account  for  medical  attendance  or 
medicines  be  paid,  if  the  officer  or  enlisted  man  be  not  on  ser- 
vice. 

50.  .  .  .When  it  is  necessary  to  employ  a  private  physician  as 
medical  officer,  the  commanding  officer  may  do  it  by  written 
contract,  conditioned  as  in  Form  15,  at  a  stated  compensation, 
not  to  exceed  $50  a  month,  when  the  number  of  officers  and 
men,  with  authorized  servants  and  laundresses,  is  one  hundred 
or  more ;  $40  when  it  is  from  fifty  to  one  hundred,  and  $30 
when  it  is  under  fifty. 

51 .  .  .  .But  when  he  is  required  to  abandon  his  own  business, 
and  give  his  whole  time  to  the  public  service,  the  contract  may 
be  not  to  exceed  $80  a  month;  and  not  to  exceed  $100,  besides 
transportation  in  kind  to  be  furnished  by  the  Quartermaster's 
Department,  where  he  is  required  to  accompany  troops  on 
marches  or  transports.  But  a  private  physician  will  not  be 
employed  to  accompany  troops  on  marches  or  transports,  except 
by  orders  from  the  War  Department,  or  in  particular  and 
urgent  cases,  by  the  order  of  the  officer  directing  the  move- 


APPENDIX.  395 

ment ;  when  a  particular  statement  of  the  circumstances  which 
made  it  necessary  will  be  appended  to  the  contract. 

52.  ..  .And  when  a  private  physician  is  required  to  furnish 
medicines,  he  will  be  allowed,  besides  the  liquidated  pay,  from 
twenty-five  to  fifty  per  cent,  on  it,  to  be  determined  by  the 
Surgeon-General. 

53.  . .  .In  all  cases  a  duplicate  of  the  contract  will  be  trans- 
mitted forthwith  by  the  commanding  officer  to  the  Surgeon- 
General  ;  and  the  commanding  officer  for  the  time  being  will  at 
once  discontinue  it  whenever  the  necessity  for  it  ceases,  or  the 
Surgeon-General  may  so  direct. 

54 ...  .  The  physician's  account  of  pay  due  must  be  sent  to 
the  Surgeon-General  for  payment,  vouched  by  the  certificate  of 
the  commanding  officer,  that  it  is  correct  and  agreeable  to  con- 
tract, and  that  the  services  have  been  duly  rendered.  But 
when  it  cannot  be  conveniently  submitted  to  the  Surgeon-Gen- 
eral from  the  frontier  or  the  field,  it  may  be  paid  on  the  order 
of  the  commanding  officer,  not  to  exceed  the  regular  amount, 
by  a  medical  disbursing  officer  or  a  quartermaster. 

55  ...  .  The  General-in-Chief  will  appoint,  on  the  recom- 
mendation of  the  Surgeon-General,  from  the  enlisted  men  of 
the  army,  or  cause  to  be  enlisted,  as  many  competent  hospital 
stewards  as  the  service  may  require. 

56 ....  As  the  hospital  stewards  are  "  attached  to  the  Medical 
Department,"  their  accounts  of  pay,  clothing,  etc,  must  be  kept 
by  the  medical  officers  under  whose  immediate  direction  they 
are  serving,  who  are  also  responsible  for  certified  statements  of 
such  accounts,  and  correct  descriptive  lists  of  such  stewards,  to 
accompany  them  in  case  of  transfer;  as,  also,  that  their  final 
statements  and  certificates  of  discharge  are  accurately  made 
out,  when  they  are  at  length  discharged  from  service. 

57.  . .  .The  senior  medical  officer  of  a  command  requiring  a 
steward  may  recommend  a  competent  non-commissioned  officer 
or  soldier  to  be  appointed,  which  recommendation  the  com- 
manding officer  shall  forward  to  the  Adjutant-General  of  the 
army,  with  his  remarks  thereon,  and  with  the  remarks  of  the 
company  commander. 

58.... When  no  competent  enlisted  man  can  be  procured, 


896  APPENDIX. 

the  medical  officer  will  report  the  fact  to  the  Surgeon-General. 
Applications  and  testimonials  of  competency,  from  persons  seek- 
ing to  be  enlisted  for  hospital  stewards,  may  be  addressed  to  the 
Surgeon-General. 

59.  .  .  .No  soldier  or  citizen  will  be  recommended  for  appoint- 
ment, who  is  not  knoion  to  be  temperate,  honest,  and  in  every 
way  reliable,  as  well  as  sufficiently  intelligent,  and  skilled  in 
pharmacy,  for  the  proper  discharge  of  the  responsible  duties 
likely  to  be  devolved  upon  him.  Until  this  is  known,  he  will 
be  appointed  as  acting  steward  by  the  medical  officer,  with  the 
approval  of  the  commanding  officer. 

60.  . .  .Hospital  stewards,  appointed  by  the  General-in-Chief, 
whenever  stationed  in  places  whence  no  post  return  is  made  to 
the  Adjutant-General's  office,  or  when  on  furlough,  will,  at  the 
end  of  every  month,  report  themselves,  by  letter,  to  the  Adju- 
tant-General and  Surgeon-General,  as  well  as  to  the  medical 
director  of  the  military  department  in  which  they  may  be  serv- 
ing; to  each  of  whom  they  will  also  report  each  new  assign- 
ment to  duty,  or  change  of  station,  ordered  in  their  case,  noting 
carefully  the  number,  date  and  source  of  the  order  directing  the 
same.  They  will  likewise  report  monthly,  when  on  furlough,  to 
the  medical  officer  in  charge  of  the  hospital  to  which  they  are 
attached. 

61.... The  jurisdiction  and  authority  of  courts-martial  are 
the  same  with  reference  to  hospital  stewards  as  in  the  cases  of 
other  enlisted  men.  When,  however,  a  hospital  steward  is 
sentenced  by  an  inferior  court  to  be  reduced  to  the  ranks,  such 
sentence,  though  it  may  be  approved  by  the  reviewing  officer, 
will  not  be  carried  into  effect  until  the  case  has  been  referred  to 
the  General-in-Chief  for  final  action.  In  these  cases  of  reduc- 
tion, the  application  of  the  man  for  discharge  from  service, 
though  not  recognized  as  of  right,  will  generally  be  regarded 
with  favor,  if  his  offence  has  not  been  of  too  serious  a  nature, 
and  especially  when  he  has  not  been  recently  promoted  from 
the  ranks. 


APPENDIX. 


307 


[It  is  urged  that  medical  officers  make  requisition  only  for  such  medicines  in  the 
following  table  as  are  deemed  indispensable.] 

Standard  Supply  Table  for  General  and  Post  Hospitals. 


ARTICLES. 


Quantities  for  one  year  for  commands  of 


From 
100  to 

200. 


From 

2oil  to 

300. 


From 

300  to 

400. 


500      i   1,000 
men.       men. 


MEDICINES. 


Acacias lb. 

Acidi  acetici lb. 

"      arseniosi oz. 

"      benzoici oz. 

"      citriei . .  .lb. 

"      muriatic! lb. 

"      nitrici lb. 

"      sulphurici lb. 

"  "         aromatic!.. .  .lb. 

"     tannici oz. 

"      tartarici lb . 

jEtheris  sulphurici  loti lb. 

Alcoholis butt. 

Aluuiiuis lb. 

Ammoniacia lb. 

Ammonias  carbon atis oz. 

muriatis lb. 

Anthemidis lb. 

Antimonii  et  potass,  tartratis.oz . 
Argenti  nitratis  (crystals). .  .oz. 

"        (fused) iz. 

Arnica? lb. 

Assafcetidae  ...    oz. 

Bismuthi  subnitratis oz. 

Camphorae lb. 

Cardamomi oz. 

Catechu lb. 

Cera?  alba>* lb. 

Cerati  rcsinae lb. 

zimplicis lb. 

"      zinci  carbonatis lb. 

Chloroform] lb. 

Collodii oz. 

Copaiba? lb. 

Creasoti oz . 

Creta?  prcparatae lb. 

Cupri  sulphatia oz. 

Emplastri  adhsesivi yds. 

"  cantharadis lb. 


2 
4 
4 

l 
l 
* 
l 
1 
l 

2 
2 
2 
24 
1 


2 
2 
4 
4 
4 

48 
2 
1 

16 
1 
2 
6 
2 


8 
4 

16 
1 
4 
4 

16 
4 
2 
4 

10 
4 
2 

4 

10 

6 


72 

2 

24 

2 

9 

3 
3 

3 

12 

12 

6 

24 

2 

6 

6 

24 

6 

3 

6 

15 

6 

3 

6 

15 

.9 


8 

24 

22^ 

4 

4 

24 

4 

4 

4 

S 

8 

8 
96 

4 

24 
32 

24 

4 
12 

4 

4 

4 
16 
16 

8 
32 

2* 

S 

8 
32 

8 

4 

8 
20 

8 

4 

8 
20 
12 


16 


5 

S 

S 

8 

16 

16 

16 

192 

8 

5 

64 

5 

S 

24 

8 

S 

'  8 

32 

32 

16 

64 

5 

16 

16 

64 

16 

8 

16 

40 

16 

8 

16 

40 

24 


*To  be  issued  I )  posts  w  hei  e  simple  cerate  cannot  be  sent  without  becoming  rancid. 


398 


APPENDIX. 


SUPPLY  TABLE  FOR  HOSPITALS— Continued. 


ARTICLES. 


Quantities  for  one  year  for  commands  of 


From 
100  to 

*  10. 


From 

200  to 

300. 


From   | 

300  to 

400. 


500 
men. 


1,000 
men. 


Emplastri  ferri lb 

"         hydrargyri lb 

"         iehthyoeolla?  • .  -yds 

Extracti  belladonna? oz 

"        buchu  fluidi lb 

"        colchici  acetici  . .  .  .oz 
"       colocynthidis  conip.oz 

'•        eolomba?  fluidi lb 

"        conii oz 

"    •    cubeba?  fluidi lb 

"        gen tiana?  fluidi  ...  .lb 

"       glycyrrhizae lb 

"        hyoscyaini oz 

"       ipecacuanha?  fluidi. lb 

"       piperis  fluidi oz 

"        pruni  virg.  fluidi. .  .lb 

"        rhei  fluidi lb 

"        sarsaparilla?  fluidi.  .lb 

"        senega?  fluidi lb 

"        senna?  fluidi lb 

"        taraxaci  fluidi lb 

"        Valeriana?  fluidi  . .  .oz 
"        zingiberis  fluidi. .  .  .11) 

Ferri  iodidi oz 

"     et  quinise  citratis oz 

"     sulphatis oz 

Gauibogia? oz 

Glycerine oz 

Guaiaci  resinae lb 

Hydrargyri  chloridi  corr. . .  .oz 
"  "         mitis...lb 

"  cum  creta lb 

"  iodidi oz 

"  oxidi  rubri oz 

Iodinii oz 

Lini   lb 

Liquoris  ammonia? lb 

"         ferri  iodidi lb 

"  potass  :  arsenitis  ...oz 
"  soda?  chlorinta?. .  .bott 
"  zinei  chloridi  . .  .  .bott 

Maguesise lb 

"        sulphatis lb 

Mas^se  pill  :  hydrargyri oz 

Mellis  despumati Hi 

Morphia?  sulphatis    dr 


1 

2 

3 

4 

J 

1 

2 

24 

3 

13 

9 

12 

2 

4 

6 

8 

1 

2 

3 

4 

1 

2 

3 

4 

8 

16 

24 

32 

1 

2 

3 

4 

1 

2 

O 

4 

1 

2 

3 

4 

1 

2 

3 

4 

6 

12 

18 

24 

2 

4 

6 

8 

4 

1 

2 

24 

l 

2 

3 

4 

l 

2 

3 

4 

l 

2 

3 

4 

2 

4 

6 

8 

| 

1 

2 

24 

1 

2 

3 

4 

1 

2 

3 

4 

8 

16 

24 

32 

4 

1 

2 

24 

2 

4 

6 

8 

4 

S 

12 

16 

2 

4 

6 

8 

2 

1 

2 

24 

2 

4 

6 

8 

4 

1 

2 

2* 

4 

1 

2 

24 

l 

2 

3 

4 

4 

1 

2 

24 

l 

2 

3 

4 

l 

2 

3 

4 

2 

4 

6 

8 

4 

8 

12 

16 

4 

8 

12 

16 

1 

2 

3 

4 

2 

4 

6 

8 

3 

6 

9 

12 

3 

6 

9 

12 

* 

1 

2 

24 

25 

50 

75 

100 

8 

16 

24 

32 

2 

4 

6 

8 

2 

4 

6 

8 

APPENDIX. 


399 


SUPPLY  TABLE  FOR  HOSPITALS— Continued. 


1,000 
men. 


My  rrhse lb  •  • 

Olei  unisi oz. . 

'•    cajuputi oz.. 

"    caryophylli oz . . 

"    cinnamomi oz. . 

"    meuthcO  piperita} oz . . 

■'    morrh.ua) .  •  .bott. . 

"    oliva) bott . . 

"    origani oz.. 

"'    ricini qt.  bott. . 

"     terebinthinse qt.  bott.. 

"    tiglii dr.. 

Opii lb-- 

Picis  abietis ..lb.. 

Plumbi  acetatis lb. . 

Potasse  acetatis lb . . 

"       bicarbonatis lb . . 

"       bitartratis lb.. 

"       chloratis lb . . 

"       nitratis lb.. 

"       sulpbatis lb . . 

Potassii  eyanureti dr.  . 

"        iodidi oz. 

Pruni  virginiana) lb. 

Pulveiis  acacia) lb . 

"        aloes oz. 

"        cantharidis oz. 

"        capsici lb. 

"        cinchona? lb. 

"        ferri oz. 

"  "     per  sulphatis  .  .oz. 

"        glycyrrhiza) oz. 

ipecacuanha) lb. 

"  "  et  opii. lb. 

"        ialapas oz. 

"       lini lb. 

"        opii lb. 

"       rhei oz. 

"        sabina) oz. 

"        sinapis  nigra) lb. 

"       ulini lb. 

Quassia) lb . 

Quinia)  sulphatis oz. 

Rhei oz. 

Sacehari lb. 


aponis 


.lb. 


i 
1 

1 
1 

1 
2 
8 
8 
4 
12 
4 
2 

4 

l 
l 
l 
l 
2 
1 
1 
i 
1 
8 

2 

4     j 

2 

1 

1 

2 

1 

4 

i 
4 

8 

4 
1 
6 

2 

JL 

10-20 

4 

20 

4 


2 

4 
16 
16 

S 
24 

8 

4 

1 

2 

2 

2 

2 

4 

2 

2 

1 

2 
16 

1 

4 

8 

4 

2 

2 

4 

2 

S 

1 

1 

8 
16 

1 

8 

2 
12 

4 

1 
20-40 

8 
40 

8 


2 
3 

Q 

3 

3 

6 
24 
24 
12 
36 
12 

6 

2 

3 

3 

3 

3 

6 

3 

3 

2 

3 
24 

2 

6 
12 

6 

3 

6 

3 

12 

2 

2 
12 
24 

2 
12 

18 

6 

2 

30-60 

12 

(it) 

12 


2i 

4 

4 

4 

4 

S 
32 
32 
16 
48 
16 

8 

24 

4 

4 

4 

4 

8 

4 

4 

2i 

4 
32 

2£ 


16 

64 

64 

32 

96 

32 

16 

5 

8 

S 

8 

8 

16 


8 
64 


8 

16 

16 

32 

8 

16 

4 

8 

4 

8 

8 

16 

4 

s 

16 

32 

2* 

5 

2* 

5 

16 

32 

32 

64 

2  J 

5 

16 

32 

4 

8 

24 

48 

8 

16 

2.V 

b 

40-80 

80-160 

16 

32 

80 

160 

16 

32 

400 


APPENDIX. 


SUPPLY  TABLE  FOR  HOSPITALS— Continued. 


Quantities  for  one  year  for  commands  of 


From 

100  to 
200. 


From 

200  to 
300. 


From 

300  to 

400. 


500 
men. 


Seillae oz. 

Serpen  tarise lb. 

Soda?  bicarbonatis lb. 

boratis lb. 

et  potass:  tartratis  ...lb. 

Spigelian lb. 

Spiritus  ammon  :  aromatici.  .oz. 
"        ajtheris  compositi. .  .lb. 

"  "        nitriei lb. 

"       lavanduhe  comp. . .  .lb. 

"        vini  galliei bott. 

S  trychn ire   dr. 

Sulphuris  loti lb. 

Sy rupi  scillse 11 1 . 

Tine-tune  aconiti  radiois  ...  .lb. . 

"         digitalis oz. 

"         ergotiv  (Dublin).,  oz.. 

"         ferri  chloric) i lb., 

"         veratri  viridis  .  ...oz.. 

Unguenti  hydrargyri lb. , 

"  "  nitratis.lb. , 

Veratriae dr.  i 

Vini  colchici  seminis lb. . 

Zinci  acetatis z. , 

"     sulphatis oz. . 

"      ohlorid oz. . 

INSTRUMENTS. 

Buck's  spongeholder  for  the 

throat no. 

Cupping  glasses  or  tins no. 

Dissecting sets. 

Lancets,  spring* no. 

"         thuinbf no. 

Obstetrical sets. 

Pocket sets. 

Probangs no. 

Pulleys sets. 

Scarificators no. 

Splints  (assorted) sets. 

Stethoscopes no. 

Stomach  pump  and  case  .  . .  .no. 
Syringes,  enema."}; no. 


4 

8 

12 

16 

J 

1 

2 

2h 

2 

4 

6 

8 

i 

1 

2 

2* 

3 

6 

9 

12 

i 

1 

2 

24 

2 

4 

6 

8 

i 

1 

2 

2i 

2 

4 

6 

8 

t 

1 

2 

24 

12 

24 

36 

4S 

1 

2 

3 

4 

1 

2 

3 

4 

3 

6 

9 

12 

1 

2 

3 

4 

4 

8 

12 

16 

4 

8 

12 

16 

1 

1 

2 

2$ 

4 

8 

12 

16 

1 

2 

3 

4 

1 

1 

2 

2£ 

1 

2 

3 

I 

5 

1 

2 

24 

i 

2 

3 

4 

i 

2 

3 

4 

i 

1 

1 

2 

i 

1 

1 

1 

12 

12 

18 

18 

1 

1 

1 

1 

I 

1 

2 

2 

4 

6 

S 

8 

1 

1 

1 

1 

1 

1 

1 

1 

6 

6 

6 

6 

1 

1 

1 

1 

2 

2 

2 

3 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

:;   1 

3 

3 

3  1 

*  Four  extra  fleams  to  each  lancet.     \ With  rases.     J  1  Davidson's;  1.  4-oz. :  1,  8-oz. 


APPENDIX. 


401 


SUPPLY  TABLE  FOK  HOSPITALS— Continued. 


ARTICLES. 


Quantities  for  one  year  for  commands  of 


From 

100  to 
200. 


From 

200  to 

300. 


From 

300  to 

400. 


500 
men. 


1,000 
men. 


Syringes,  penis,  glass no. 

"  "       metallic. . .  .no. 

"         vagina* no . 

Teeth  extracting sets.  . 

Tongue  depressor  (hinge). .  .no. , 

Tourniquets,  held no .  . 

"  spiral no. 

Trusses,  hernia; no. 

BOOKS. 

Anatomy cop. 

Chemistry cop. 

Dispensatory    cop. 

Medical  Dictionary cop. 

Formulary cop. 

"        Jurisprudence  and 

Toxicology cop. 

"        Practice cop. 

Obstetricy cop. 

Regulations  for  Med.  Dep't.cop. 

Surgery cop . 

Blank no. 

Case no. 

Meteorological  Register  ...  .no. 

Order  and  Letter no. 

Prescription no. 

Register no. 

Requisitions 
Returns 
Reports  of  sick 

HOSPITAL  STORES. 

Arrowroot lb. 

Barley lb. 

Cinnamon lb. 

Cloves oz. 

Cocoa Hi. 

Farina lb. 

Ginger,  ground  (Jamaica) . .  .lb. 

Nutmegs oz. 

Tea lb. 

Whiskey,  bottles  of doz. 


2 

4 

6 

8 

6 

12 

18 

24 

3 

3 

3 

3 

1 

1 

1 

1 

1 

1 

1 

1 

4 

4 

6 

6 

1 

1 

2 

2 

3 

6 

9 

12 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

2 

1 

1 

1 

2 

2 

3 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

5 

10 

15 

20 

20 

40 

60 

80 

i 

1 

2 

2i 

4 

S 

12 

16 

10 

20 

30 

40 

5 

10 

15 

20 

i 

1 

2 

2i 

4 

8 

12 

16 

20 

40 

60 

80 

2 

4 

6 

s 

16 

36 

6 

2 

2 

10 

4 

24 


40 

160 

5 

32 

80 

40 

5 

32 

160 

16 


34 


*  Hard  india-rubber,  1 ;  glass,  2. 


402 


APPENDIX. 


SUPPLY  TABLE  FOR  HOSPITALS— Continued. 


Quantities  for  one  year  for  commands  of 


From 

From 

From 

100  to 

200  to 

300  to 

200. 

300. 

400. 

500 
men. 


Wine,  bottles  of doz. 

BEDDING. 

Bed  sacks no. 

Bedsteads,  iron no. 

Blankets,  woollen no. 

Coverlets no. 

Grutta  percha  cloth jds. 

Mattresses no. 

Musquito  bars no. 

Pillow  rases no . 

ticks no. 

Sheets no. 


FURNITURE,  DRESSINGS,  ETC. 

Bandages,  suspensory* no. 

Binders'  boardsf no. 

Corks,  assorted doz. 

Corkscrews no. 

Cotton  batting 11). 

"         wadding lb. 

Flannel,  red yds. 

Funnels,  glass no. 

"         tin no. 

Hatchets no. 

Hones  (in  wood)j  ■ no. 

Ink  powder papers. 

Inkstands no. 

Linen yds. 

Lint lb. 

Measures,  graduated no. 

•'  tin sets. 

Medicine  cups  and  glasses||  .no. 

Mills,  coffee no. 

Mortars  and  pestles,  glass  ..no.. 

"  "  "  iron  ...  no. 

"           "          "          wedge- 
wood  no. 

Muslin yds. 

Needles,  sewing no. 

Oiled  silk  or  gutta  percha  tis- 
sue, or  india-rubber  tissue. yds. 


2 

4 

6 

8 

10 

20 

30 

-10 

6-1 0 

12-20 

18-30 

24-10 

10-20 

20-40 

30-00 

40-80 

10 

20 

30 

40 

4 

6 

8 

10 

2 

4 

6 

8 

0-10 

12-20 

18-30 

24-40 

25 

50 

75 

100 

10 

20 

30 

40 

-10 

80 

120 

200 

4 

8 

12 

16 

•1 

6 

8 

12 

12 

24 

36 

48 

1 

1 

2 

2 

1 

2 

3 

4 

1 

2 

3 

4 

5 

10 

15 

20 

1 

1 

2 

9 

1 

1 

2 

2 

1 

1 

2 

2 

1 

1 

1 

1 

2 

9 

3 

3 

1 

1 

2 

2 

5 

10 

15 

20 

4 

6 

8 

10 

3 

3 

4 

6 

1 

1 

1 

1 

■  3 

6 

1) 

12 

2 

2 

2 

3 

1 

1 

2 

2 

1 

1 

1 

1 

1 

2 

2 

3 

25 

50 

75 

100 

25 

25 

25 

25 

4 

6 

6 

8 

Assorted,    f  18  inches  by  4.    J  inches  by  1.    |j 2  cups  to  1  glass. 


APPENDIX. 


403 


SUPPLY  TABLE  FOR  HOSPITALS— Continued. 


ARTICLES. 


Quantities  for  one  year  for  commands  of 


From 
100  to 
200. 


From 
200  to 
300. 


From 
300  to 

400. 


500 
men. 


1.000 
men. 


runs,  bed no.  . 

Paper  envelopes* no. . 

"      filtering quires. . 

."      wrapping quires . . 

"      writingf quires. . 

Pencils,  hair no.  . 

"         lead no. . 

Pens,  steel doz.  . 

Pill  boxes papers.  . 

"    machine no.. 

Pins,  assorted papers. . 

Quills no. . 

Rain  gauges u o . . 

Razors no. . 

Razor  strops no. . 

Scales  and  weights,  apothe- 
cary's   sets.. 

Scales  and  weights,  shop. .  sets. . 

Scissors no . . 

Sheep  skins,  dressed no. . 

Silk,  surgeons oz . . 

"     green yds.. 

Spatulas no. . 

Sponge lb. . 

Tape! pieces.. 

Thermometers    and   hygro- 
meters   no. . 

Thermometers no. . 

Thread,  linen oz. . 

Tiles no. . 

Tow lb.. 

Towels no.. 

Twine lb.. 

Urinals no.  . 

Vials,  assorted loz, . 

Wafers  (V  oz.  boxes) no. . 

Wax,  sealing sticks. . 


2 

2 

3 

4 

100 

125 

150 

200 

i 

1 

2 

2 

10 

12 

15 

15 

12 

20 

20 

20 

12 

18 

24 

30 

6 

8 

10 

12 

2 

3 

3 

4 

3 

6 

9  • 

12 

1 

1 

1 

1 

2 

4 

6 

8 

25 

24 

50 

50 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

2 

2 

1 

1 

1 

1 

2 

2 

2 

3 

4 

6 

8 

10 

X 

j. 

i 

4 

i 

1 

2 

2i 

:3 

Q 

4 

6 

3 

1 

f 

i 

4 

8 

12 

16 

2 

2 

2 

2 

1 

1 

1 

1 

4 

4 

G 

6 

2 

3 

3 

3 

1 

2 

9 

3 

20 

30 

50 

75 

1 

1 

1* 

U 

2 

3 

5 

6 

6 

12 

18 

24 

1 

1 

2 

2 

3 

3 

4 

4 

250 

20 
30 

50 
18 

6 

24 

1 

16 

50 

1 

2 
2 

2 
1 
4 

12 
1 
5 

12 
1 

32 

2 
1 


150 

3 

10 

48 

3 

6 


*  Assorted,  '■'<  sizes — "Official  business''  printed  on  each,    f  Foolscap,  letter  and 
note — white:  blue  ruled,    t  One  quarter,  woollen:  three  quarters,  cotton. 


404 


APrENDlX. 


If  the  following  articles  of  Hospital  Furniture  cannot  be  ob- 
tained with  the  hospital  fund,  they  may  be  procured  from  a 
quartermaster  or  medical  disbursing  officer,  by  special  requisi- 
tion : 


ARTICLES. 


Basins,  wash. 

Bowls. 

Brushes. 

Buckets. 

Candlesticks. 

Clothes  Lines. 

Cups. 

Dippers  and  Ladles. 

Graters. 

Gridirons . 

Kettles,  tea.  . 

Knives  and  Forks. 

Lamps  and  Lanterns. 

Locks  and  Keys. 


Mugs. 
Pans,  frying. 

"       sauce. 
Pitchers. 

Plates  and  Dishes. 
Pots,  chamber  and  chair. 

"     coffee  and  tea. 
Sadirons. 
Shovels,  fire. 
Snuffers. 
Spoons. 

Tongs  and  Pokers. 
Tumblers. 
Woodsaws. 


APPENDIX. 


405 


Standard  Supply  Table  for  Field  Service. 

Quantities. 

ARTICLES.                                       |   Reg't  1     Bat.    1  Comp. 
!  3  mos.  |  3  mos.  |  3  mus. 

MEDICINES. 

Acidi  aeetiei lb. . 

"      sulph.  aroniatici Hi. . 

"      tannici oz. . 

iEthcris  sulphurici  loti lb.  . 

Alcoholis bott. . 

Al ii minis lb.  . 

Ammonite  carbonatis oz. . 

Antimnnii  et  potass,  tartratis oz. . 

Argenti  nitratis  (crystals) oz. . 

"         (fused) oz.. 

Camphora? lb. . 

Cerati  resina? lb. . 

"      simplicis lb.  . 

Chloroformi lb. . 

Copaibas lb. . 

Creasoti oz. . 

Cupri  sulpbatis oz. . 

Emplastri  adha?sivi yds. . 

"  eantharidis lb. . 

"  iehthyocolla? yds.. 

Extracti  belladonna} oz . . 

"     colchiei  acetici oz. . 

"'     colocynthidis  comp oz. . 

'■'     glycyrrhizae lb. . 

Hydrargyri  ehloridi  corrosivi oz. . 

_  "     '  "         mitis lb.. 

Iodinii oz,  # 

Liquoris  Ammonia? lb. . 

"      potass,  arsenitis oz.. 

Magnesia?  sulpbatis. lb. . 

Massa?  pil :  hydrargyri oz .  . 

Morphia  sulpbatis dr. . 

Olui  caryuphylli oz. . 

"    mentis  a?  piperita? oz. . 

"    olivae bott. . 

"    ricini ([t.  bott.. 

"    terebiutbina? qt.  bott. . 

"    tiglii dr.. 

Pil  ul :  cathartic:  comp:   (U.S.) doz.  . 

opii  (U.  S.) doz.. 

"       quinia?  sulpbatis  (3  grs.) loz. . 

Plmubi  acetatis lb. . 

Potassa?  bicarbouatis 11,. , 

■'       chloratis 1!,.  , 

"       nitratis ..lb.. 


1 
1 

2 
2 

10 
1 

16 
2 
2 
2 
4 
2 


4 
10 

4 
10 

1 

2 
16 


2 

4 
4 
4 
20 
16 
4 
1 
2 
8 
12 
8 
2 
8 
8 
8 

1 
2 
1 


1 
1 
5 
i 
8 
1 
1 
1 
2 
1 
4 
1 
1 
1 
2 
5 
2 
5 
1 
1 
S 
1 
I 
I 
2 
2 
2 
10 
8 
2 
1 
1 
4 
6 
4 
1 
4 
4 
4 
1 

i 


406 


APPENDIX. 


SUPPLY  TABLE  FOR  FIELD  SERVICE— Continued. 


Quantities. 


Keg  t   I    Bat.     I  Comp. 
3  mos.     3  mos.     3  inos. 


Potassii  iodidi oz. . 

Pulveria  acaciae lb. . 

capsici lb.. 

"       ferri  per  snlpbatis /..  . 

"       ipecacuanha; lb.. 

"  "  et  opii oz.. 

"       lini lb.. 

"       opii lb.. 

'■        rlici lb.  . 

"       sinapis  nigros lb. . 

Quinise  sulphatis oz. . 

Sacchari lb. . 

Saponis lb. . 

Sodas  bicarbonatis lb. . 

Spiritus  ammonias  aroniatici oz.  . 

"      astheris  nitjrici lb. . 

"      vini  gallici bott. . 

Tincturae  ferri  chloridi lb. . 

"      opii oz. . 

Unguenti  hydrargyri lb. . 

"  "  nitratis lb.. 

Zinci  acetatis oz.  . 

"     sulphatis oz.. 

"     cblorid oz. . 

INSTEUMKNTS. 

*  A  case  of  instruments  for  general  operations, 

containing  all  instruments  necessary  for  am- 
putations, resections  and  trephining. 

*  A  pocket  case,  containing  all  instruments  re- 
quired in  the  daily  routine  of  surgical  dress- 
ings. 

*  A  case  of  assorted  catheters. 

Buck's  spongeholder  for  the  throat no. , 

Cupping  glasses  and  tinsf no. 

Lancets,  spring no. 

"         thumb  (with  cases) no. 

Pocket . sets. 

Probangs,  whalebone no. . 

Scarificators no.  - 

Splints  (major) sets., 


s 

4 

4 

2 

A 

j. 

4 

2 

1 

s 

3 

4 

16 

8 

2 

1 

i 

* 

12 

6 

24 

12 

10 

5 

8 

4 

1 

J 

4 

2 

2 

1 

24 

12 

1 

i 

16 

8 

1 

I 

i 

i 

2 

1 

2 

1 

1 

i 

1 

l 

1(5 

8 

1 

1 

6 

4 

1 

1 

12 

6 

4 

2 

1 

1 

*These  are  instruments  which  a  field  surgeon  cannot  do  without,  and  have, 
apparently,  been  accidentally  omitted  from  the  supply  table  of  the  Confederate 
service. 

fJIalf  glass,  half  tin. 


APPENDIX. 


407 


SUPPLY  TABLE  FOR  FIELD  SERVICE— Continued. 


ARTICLES. 


Quantities. 

Reg't  I    Bat.     I  Comp. 
|  3«nos.  I  3  mos.  I  3  mos. 


Syringes,  enema* no. 

"         penis,  glass no. 

"  "      india-rubber no. 

Teeth  extracting sets. 

Tongue  depressor  (hinge) no. 

Tourniquets,  field no. 

"  spiral no. 

Trusses,  hernia no. 


Anatomy  (surgical) cop. . 

Medical  Practice cop. . 

Regulations  for  medical  department cop. . 

Surgery  (operative)   cop. . 

Thompson's  Conspectus cop. . 

Blank no. . 


HOSPITAL   STORES. 


Arrowroot 

Candles  (sperm). 
Farina 


Ginger,  (fluid  extract). 

Nutmegs 

Tea 


.lb. 


.lb. 


Whiskey,  bottles  of doz 

BEDDING. 


Blankets,  woollen  (brown) no. 

Blanket  cases  (of  canvas,  after  pattern)  ..  .no. 

Gutta  perch  a  cloth yds. 

"     bed  coversf no. 

Musquito  bars no. 

FURNITURE  AND  DRESSINGS. 

Bandages, J  roller,  assorted doz. 


10 
2 

10 
1 
8 

30 
2 


20-40  10-20 
1  for    10    bli 
4 
4 
6 


12 


14 


10 

i  nkets 
2 
2 
4 


*1  Davidson's;  1  hard  rubber,  6  oz. 

fSo  constructed,  as  to  form,  when  united  a  continuous  spread,  or  covering 
11  dozen,  1  inch  wide.  1  yard  long. 
2      '•       2  «        3 


3 
4 


408 


APPENDIX. 


SUPPLY  TABLE  FOR  FIELD  SERVICE— Continued. 


Reg't 

.">  DDLOS 


Quantities. 
I    Bat 


Comp. 
3  mos.  I  3  mos. 


Bandages,  suspensory,  assorted no. 

Binders'  boards  (18  inches  by  4) no. 

Buckets,  leather no. 

Corks,  assorted doz , 

Corkscrews no , 

Cotton  batting lb. 

"        wadding lb. 

Flannel  (red) yds. 

Hatchets no, 

Hones  (4  inches  by  1,  in  wood) no 

Ink,  2-ounce  bottles no 

Knapsacks,  hospital* no 

Lanterns no 

Lint lb 

Litters  and  stretchers,  hand* no 

"        horse* no 

Measures,  graduated,  assortedf no 

Medicine  chests no 

"         cups  and  glasses^ no 

"         panniers no 

Mess  chests  (see  note) no 

Mills,  coffee no 

Mortars  and  pestles,  Wedgewood  (small).,  .no 

Muslin yds 

Needles,  sewing  (assorted,  in  a  case) no 

Oiled  silk  or  gutta  percha  tissue,  or  india-rub- 
ber tissue yds 

Pans,  bed[| no 

Paper  envelopes,  assorted^ no 

Paper,  wrapping quires 

"        writing^ quires 

Pencils,  hair no 

"  lead  (of  Faber's  make,  No.  2) no 

Pens,  steel doz 

Pill  boxes  (wood j papers 

'•  (tin)  no 

Pins,  assorted  (large  and  medium) papers 

Razors no 

Razor  strops > no 


12 

6 

18 

9 

4 

o 

12 

6 

2 

1 

2 

1 

2 

1 

5 

3 

2 

1 

1 

1 

12 

6 

4 

2 

8 

4 

4 

2 

6 

3 

2 

1 

2 

1 

20 

10 

25 

25 

8 

4 

2 

1 

100 

50 

6 

3 

12 

6 

24 

12 

12 

6 

4 

2 

2 

1 

6 

6 

4 

2 

1 

1 

1 

1 

1 
1 

5 
25 

2 
1 
25 
1 
3 
6 
3 
1 
1 
6 
2 
1 
1 


*  According  to  pattern. 

|  6  ox.  12  oz.,  minim. 

I  2  cups  to  1  glass. 

|!  Of  hanl  india-rubber  or  other  material.     Shovel. 

$50  letter,  25  note.  25  large.    ''OfnciiU  Business"  printed  on  each. 

1i  2  foolscap  6  letter,  4  note,  white ;  blue  ruled. 


APPENDIX. 


409 


SUPPLY  TABLE  FOR  FIELD  SERVICE— Continued. 


ARTICLES. 


Quantities. 


Reg't 
3  mos. 


Bat. 
3  mos. 


Comp. 
.3  mos. 


Scales  and  weights,  apothecary's sets 

Scissors no 

Sheep  skins,  dressed no 

Silk,  surgeons' oz 

"     green yds 

Spatulas no 

Sponge  (washed) lb 

Tape pieces 

Thread,  linen oz 

Tiles no 

Towels no 

Twine lb 

Urinals no 

Vials,  assorted  (1  oz.  and  2  oz.) doz 

Wafers  (J  ounce  boxes)  .". no 

Wax,  sealing sticks 


1 

1 

4 

2 

4 

2 

i 

i 

1 

i 

6 

3 

1 

I 

4 

2 

9 

* 

1 

2 

1 

40 

20 

± 

4. 

4 

4 

2 

4 

2 

1 

1 

2 

1 

1 

2 
1 
i 

4 

4 

2 

i 
1 
1 
1 

10 

j. 

i 
l 
l 
l 


NOTE    TO    PRECEDING    TABLE. 
Furniture  of  Mess  Chest. 


8  Basins,  tin. 

2  Boxes,  pepper  and  salt. 

6  Cups,  tin. 

4  Canisters  (for  tea,  coffee,  sugar 

and  butter). 

2  Dippers  and  ladles. 

1  Grater. 

1  Gridiron. 

1  Kettle,  tea,  iron. 

12  Knives  and  forks. 


6  Mugs  (Britannia,  half-pint). 

1  Pan,  frying. 

1   Pan,  sauce. 

8  Plates  (6)  and  dishes  (2),  tin. 

1  Pot,  iron. 

2  Pots,  coffee  and  tea,  tin. 

12  Spoons,  iron  [table  (6)  and  tea 

(«)]■ 

1  Tray,  tin. 

6  Tumblers,  tin. 


The  Standard  Supply  Tables  contain  all  the  articles  to  be  purchased 
by  medical  purveyors,  except  on  the  orders  of  the  Surgeon-General; 
but  any  less  quantity  may  be  required  or  any  article  omitted  at  the 
discretion  of  the  medical  officer. 

35 


,,,...,.  ,. 

|| 

"Vi-EI'X" 

'.r,' 

. 

■■ 

MS; 

i  •;.■  . 

APPENDIX. 


411 


Form  1 — Continued. 
DISCHARGES  ON  SURGEON'S  CERTIFICATE,  AND  DEATHS. 


Name. 

Rank. 

* 

3 

o 
O 

Date  of  dis- 

Date  of 

Surname. 

Christian 

name. 

1  service. 

death. 

REMARKS. 


Notes. — Discharges  on  Surgeon's  certificate,  and  deaths  occurring  among  those 
of  the  command  not  on  sick  report,  will  be  also  reported,  but  separated  from  the 
Others  by  a*double  line  drawn  across  the  page.  The  remarks  will  in  each  case 
Bpecify  the  manner  in  which  the  disease  originated,  when  it  is  known. 

In  every  case  of  the  death  of  an  officer,  whether  on  duty  or  not,  a  special  report 
is  to  be  made  to  the  Surgeon-General 


412 


APPENDIX. 
Form  1 — Continued. 

ENDORSEMENT. 


REPORT  OF  SICK  AND  WOUNDED. 

FOR.  THE 

Quarter  ending  186  , 

Station : 


Surgeon. 


COMMAND. 


Regiments. 


Companies. 


APPENDIX. 


413 


Ai-fi 


*"  .5 
1^ 


e 

it 


o1? 


■h. 


< 

no 

CU 
o 
o 

E-    5 
-*    > 

a  (B 
is  s 
a 

Rank.             Post  or  station. 

1 

H 
12! 

d 

m  O  c'  U  (D  5) 
.  &S  if-  2  5 
-     O   >   C  +a  B 

5  ots:^ 
3 Sao =  ~j= 

Qrj     c   S   3  ^c   a)  *^ 


_>> 


&  t-  S  -u'  r   S 


•-  «  a 

13    «  Tl 


c2, 


H    C3    O 


B»aS 


:  8  o  s  5 


fcS- 


414 


APPENDIX. 


03 

•pireq  uq 

•o^a  'papnadxa  ju^ox 

•esn 

•^nspiooT!  apr^'pioA'Bnn 
£c[    pa^oj^sop   jo   ^soq; 

•pgnssj 

•5[0is  gqj  q^TM.  pgpuadxg; 

•p3}ox 

■tutty 

-oj  ^sv\  aonis  paAiaoa'jj 

•njruaj  )sv\  %v  ptreq  uq 

to 
K 
W 

O 

<  . 

a  go 

<  2 

«  3 

!E    ^ 

^O" 

CO 

K   S 
►^    O 

o 
PS 

■>"*  5 


.£^ 


APPENDIX. 


415 


'>• 


O     e 
PR      5 


& 

oa 

'I^0! 

•8  -0M  'fOA 

•J5  -0N  ""OA 

'9  "OM  'noA 

•q  -or  -no  a 

•f  -ox  -noA 

•g  -or  -noA 

(3 
j» 

o 

H 

K 

TK»ox 

•g  -ojtf  -no a 

■f  -o^r  -noA 

■g  -o^  -noA 

-6  -0JS[  -™A 

'I  'ON  -no A 

(S 

o 

eft 
« 

e  a 

<  3 

&  ^ 

H 

o 

Eh 
« 

416 


APPENDIX. 


13 

o> 

+3 

0 

cS 

£ 

a 

cS 

-a 

a 

O 

<« 

M 

Eh 

O 

■<   ai 

<*    K) 

<!  a 

a  ^ 

o  ^ 

_    S5 

«  « 

►J    o 

o 

E- 

e 

«, 

•d 

o> 

a 

rt 

► 

13 

a 

c« 

.a 

a 

O 

f& 

rO 

N 

■— ' 

o 

DQ 

PS 

B 

H 

O 

-4     03 

K    H 

m  s 

o  £ 

K 

C   -4 

K    S> 

^O" 

'£ 

x    03 

J      0 

' 

!s 

o 
'a 

0> 

o 

o 

M 

PS 

.i 

c« 

o3 

■0 

O 

|3 

» 

< 

«tj 

-a  <s 


Rs 


APPENDIX. 


417 


en     M 


&  8 


M  -2   -  ? 


j       &5 


SJ2 


S> 

£ 

rti 

<0 

J-. 

fco 

=2 

cS 

418 


ArPENDIX. 


H    « 


APPENDIX. 


410 


en 

W 

« 

< 

W 

tf 

•a?a 

■o^g 

•o?a 

=5 

•88J500 

•ilpu'ujg; 

©■ 

■ani^ 

& 

•tiaX 

o 

•jtfSng 

•aoi-jj 

1-5 

a 

H 

«l 

ft 

420 


APPENDIX. 


The    remarks    will 
note  to  whom  the  ar- 
ticles were  delivered ; 
what  money,  etc.  were 
left  by  those  who  die, 
and    to    whom    they 
were  given. 

•oj5i 

•0}3 

•343 

■sipusd\iuj{ 

•Sia^snjf 

'•>1K 

•srrei9A() 

•s^a^pef 

•sreog 

■XirediaoQ 

J§ 

ID    U 

A  ° 

a 
3 

3 

cS 

d 

o 

APPENDIX. 


421 


o5 

M 
» 

a 

The  remarks  will  state  how  articles  have  been 
lost,  and  by  whom  destroyed,  or  the  persons  sus- 
pected, etc. 

•pj'BAigjs  o%  pgnjn}9)j 

•J9pJ0  A"q  p9jf0J;S9(J 

•;no  umom 

•ijsoq; 

•o;a 

•o?a 

•SJJJOtf 

•S9ATU2 

•suoodg 

•S9in82 

■s^a^at-jg 

■sijaaqg 

■sj[obs  pag; 

■sj[nng[ 

•n9q3;i5(  .10  pjtfii  jo  -oj>j 

422 


APPENDIX. 


rH 

Ph 

1-1 

K 

H 

H 

c/J> 

I— i 

« 

O 

o 

w 

Ph 

Pd 

w 

PS 

m 

•paia 

•qSno[jnj  oq 

•[■Djidsoii  iiuauaS  0}  ?uag 

•aoiAjas  raojj  poSjuqasifl 

•p8^J0S3(J 

•A^np  o}  panan^ay; 

•pa^irapy 

j 
ft 

s 

o 
o 

•Xu'cdraoQ 

•sdaoo  jo  ^aoraiSa'jj 

•jfa^y; 

Names. 

APPENDIX. 


428 


•a 

OQ 

>> 

EH 

t> 

■3 

a 
o 

NAMES. 

bCd   53   a   o 

a  a  .2  <§  EH 

3    .,  ®  -r 
-^  ^  a  it  -^3 
.3  -3  ft  * .« 

-a  3-^«  ° 

t_,  o  <~   o   9 


a    S3     i     03  r3 

si  «  H/ft* 


P   H  Q   go  o8   a 


o 


C3  —I 


_£  13    ?  53  -3    ^>  03  ^ 

&  .Z  ^r,        S3   a   o  "   a>  >a 


-  S3 


S3   ft 


§    &  J3   2, 


3    3    o 


£J5 

|    °    |  «g  fj  ^ 
03         "S    fe^i    o 


6  e>  .z  a  CQ 

+^    _3    r^H    •£-    ^ 


p_,-u      .      -03    «    =3 

~.o  h3  g  J  *°  =« 

J  ^  ^  '£  -?<  °  § 


o  a 


d 


^    -^    M 

«3     2     53 


5  -a  . 


»  a  m 


13  J3  B 

ta  °  .2 


-a  ■*> 


j,  a  to 

+3   5   tf  2   2   e3 

3      «"  *=  _  t" 
s  a  °  ts  ° 

CO   >>£-£  13 

£|     53     n  O  +J    Fj    . ..    H 

53  rO     0     Pi    m   -w 

sj  "3  _  a 

o  ™-  s 

53     53    M    S3    ,„  03 


£ 

X"^ 


xa  es  a 


03 


o  q 


53  a 


53  X,  £  £  °  a 
-  £  °  m      *«  a 

^  ^o  „  .2  £  & 


53     53  ^    O  ' 

Sj  .>        S    "S 


O    O    O    d    h 

o  —  M  ."£  cs 
M  c^  a.rt 

o   op' 


'  a^a  "" 


x    >-.  —  ^  r—   a 

S  §    5   3 

53  'S  CO  ^ 

.a 


0  '- 


2   *. 


-.: 


C3 


03 


03     53 

„    t.    J 

a=2  = 


/^ 


-ar-^53  ^o-ra^  _ 

-tJ^c'^a3"S     -53t< 

3     C3     bC  !-.  ^ 
•- >    _  •«  .O  -w 


■a  ■- 


03     03     „  ^H 

a  is  2  o 


rt  'o    53     c     x 


.2  .2  ft  is 
"§  ^  2^a 

a—  S  2 


^a  o 
„   o 

a« 

J  03 
w  S 

'3  S 

&a 

2  ° 


^3  ^i  .S  'd  53  •z'H  ^3x3 


424  APPENDIX. 

Form  13. 
ARMY  OF  THE  CONFEDERATE  STATES. 
(Coat  of  Arms.) 
Certificate  of  Disability  for  Discharge. 
A  B,  of  Captain  's  company,  ( — ),  of  the  regi- 
ment of  Confederate  States ,  was  enlisted  by , 

of  the regiment  of ,  at ,  on  the day  of , 

to  serve  years ;  he  was  born  in  ,  in  the   State  of 

,  is  years  of  age, feet  inches  high, 

complexion, eyes, hair,  and  by  occupation,  when  en- 
listed,   .     During  the  last  two  months  said  soldier  has  been 

unfit  for  duty days. 

(The  company  eorrfmander  will  here  add  a  statement  of  all  the 
facts  known  to  him  concerning  the  disease  or  wound,  or  cause  of 
disability  of  the  soldier ;  the  time,  place,  manner,  and  all  the 
circumstances  under  which  the  injury  occurred,  or  disease  origi- 
nated or  appeared ;  the  duty  or  service  or  situation  of  the  soldier 
at  the  time  the  injury  was  received  or  disease  contracted,  or  sup- 
posed to  be  contracted  ;  and  whatever  facts  may  aid  a  judgment 
as  to  the  cause,  immediate  or  remote,  of  the  disability  and  the 
circumstances  attending  it.) 

C  D,  Commanding  Company. 
(When  the  facts  are  not  known  to  the  company  commander, 
the  certificate  of  any  officer,  or  affidavit  of  other  person  having 
such  knowledge,  will  be  appended.) 

I  certify  that  I  have  carefully  examined  the  said of 

Captain 's  company,  and  find  him  incapable  of  perform- 
ing the  duties  of  a  soldier  because  of  (here  describe  particularly 
the  disability,  wound,  or  disease  ;  the  extent  to  which  it  deprives 
him  of  the  use  of  any  limb  or  faculty,  or  affects  his  health, 
strength,  activity,  constitution,  or  capacity  to  labor  or  earn  his 
subsistence).  The  Surgeon  will  add,  from  his  knowledge  of  the 
facts  and  circumstances,  and  from  the  evidence  in  the  case,  his 
professional  opinion  of  the  cause  or  origin  of  the  disability. 

E  F,  Surgeon. 
(duplicates). 
Notes. — 1.  When  a.  probable  case  for  pension,  special  care  must  be  taken  to  state 
the  degree  of  disability. 
2.  The  place  where  the  soldier  desires  to  be  addressed  may  be  here  added 
Town—  County —  State — 


APPENDIX. 


425 


^    < 


id 
'3 

'5 

£ 

•siaj.iBnb  nj 

•jujidsoq  ttj 

■p^ia 

•l^tflsoq 

•paSanqosiQ; 

•jfynp  o^  psajnp'jj 

o 

5-i 

•saojiunb  nj 

•jujidsoq  nj 

•5[.")tS   UD51T?X 

s  =. 

c  g 

1-s 

•S.I3J.Il!llb  UJ 

•jc^idsoq  nj 

< 

6 
o 

< 
A 

36 


42(j  APPENDIX. 

Form     15. 
CONTRACT  WITH  A  PRIVATE  PHYSICIAN. 

This  contract,  entered  into  this day  of ,  18 — , 

at ,  State  of  ,  between ,  of  the  C.  S. 

Army,  and  Dr. ,  of  ,  in  the   State  of , 

witnesseth,  that  for  the  consideration  hereafter  mentioned,  the 

said  Dr. promises  and  agrees  to  perform  the  duties  of 

a  medical  officer,  agreeably  to  the  Army  Regulations,  at 

{and  to  furnish  the  necessary  medicines).     And  the  said  

promises  and  agrees,  on  behalf  of  the  Confederate  States, 

to  pay,  or  cause  to  be  paid,  to  the  said  Dr. ,  the  sum 

of dollars  for  each  and  every  month  he  shall  continue  to 

perform  the  services  above  stated,  which  shall  be  his  full  com- 
pensation, and  in  lieu  of  all  allowances  and  emoluments  whatso- 
ever {except  that  for  medicines  furnished,  which  shall  "be  at  the 

rate  of per  cent,  on  his  monthly  pay,  to  be  determined  by 

the  Surgeon-General).  This  contract  to  continue  till  determined 
by  the  said  doctor,  or  the  commanding  officer  for  the  time  being, 
or  the  Surgeon-General. 

[seal.] 

Signed,  sealed,  and  delivered,  ) 
in  presence  of —  ) 

[seal.] 


I  certify  that  the  number  of  persons  entitled  to  medical  at- 
tendance, agreeably  to  regulations,  at is  ,  and  that 

no  competent  physician  can  be  obtained  at  a  lower  rate. 

,  Commanding  Officer. 


AL'PENDIX. 


427 


Form    16. 

A  Monthly  Statement  of  the  Hospital  Fund  at 
month  of ,  186 — . 


-.  for  the 


Dr. 

To  balance  due  hospital  last  month,  ... 

1,532  rations,  being-  Avhole  amount  due  this  month, 
at  9|  cents  per  ration,         ...         - 


Cr. 

By  the  following  provisions,  at  contract  prices: 


283£     lbs.  of  pork,  at  6  cents  per  pound, 

600       lbs.  of  fresh  beef,  at  4c.  per  pound, 

1,61 2 T2g  lbs.  of  flour,  at  2  cents  per  pound, 

10       lbs.  of  hard  bread,  at  3^c.  per  lb. 

70       lbs.  of  rice,  at  6  cents  per  pound, 

56       lbs.  of  coffee,  at  9  cts.  per  pound, 

193-Jg  lbs.  of  sugar,  at  8  cts.  per  pound, 

1 7^     qrts.  of  vinegar,  at  5c.  per  quart, 

15T5g  lbs.  of  candles,  at  12c.  per  pound, 

61^     lbs.  of  soap,  at  6  cents  per  pound, 

16|     qrts.  of  salt,  at  3  cents  per  quart, 

12       galls,  molasses,  at  28c.  per  gallon, 


PURCHASED. 

2  prs.  of  chickens,  at  87JC.  per 

pair,         - 
4  qts.  of  milk,  at  7c.  per  quart, 

3  doz.  oranges,  at  25c.  per  doz. 

Total  expended, 
Balance  due  this  month, 


$17 

01 

27 

60 

32 

244 

0 

35 

4 

20 

5 

04 

15 

51 

0 

85* 

1 

83f 

3 

674. 

0 

50* 

3 

36 

[12  18J 


$  0  00 
145  54 


114  96f 
$30  574. 


-,  Surgeon. 


[  Date.] 


428  appendix. 

Form   17. 
FORM  OF  A  MEDICAL  CERTIFICATE, 

FOR   LEAVE    OF   ABSENCE. 

of  the regiment  of ,  having  applied  for 


a  certificate  on  which  to  ground  an  application  for  leave  of 
absence,  I  do  hereby  certify  that  I  have  carefully  examined  this 

officer,  and  find  that .     [Here  the  nature  of  the  disease, 

wound,  or  disability,  is  to  be  fully  stated,  and  the  period  during 
which  the  officer  has  suffered  under  its  effects.]  And  that,  in 
consequence  thereof,  he  is,  in  my  opinion,  unfit  for  duty.  I  fur- 
ther declare  my  belief  that  he  will  not  be  able  to  resume  his 

duties  in  a  period  less  than .     [Here  state  candidly  and 

explicitly  the  opinion  as  to  the  period  which  will  probably  elapse 
before  the  officer  will  be  able  to  resume  his  duties.  When  there 
is  no  reason  to  expect  a  recovery,  or  when  the  prospect  of 
recovery  is  distant  and  uncertain,  it  must  be  so  stated.] 

Dated ,  this day  of . 


Signature  of  the  } 
Medical  officer.    | 


Al'l'ENDlX. 


429 


APPENDIX.  48 L 


EXTRACTS 


FROM    TITR 


REGULATIONS  FOR  THE  UNITED  STATES  ARMY. 

(Edition  of  1857.) 

QUARTERMASTER'S  DEPARTMENT. 

715.  .Provides  "that  soldiers  be  not  permitted  to  leave  the 
ranks  to  assist  the  wounded,  unless  by  express  permission,  which 
is  only  to  be  given  after  the  action  is  decided.  The  highest 
interest  and  duty  is  to  win  the  victory,  which  only  can  insure 
proper  care  of  the  wounded." 

716.. "Before  an  action,  the  Quartermaster  of  the  division 
makes  all  the  necessary  arrangements  for  the  transportation  of 
the  wounded.  He  establishes  the  ambulance  depots  in  the  rear, 
and  gives  his  assistants  the  necessary  instruction  for  the  service 
of  the  ambulance  wagons,  and  other  means  of  removing  the 
wounded." 

717.  ."The  ambulance  depot,  to  which  the  wounded  are  car- 
ried or  directed  for  immediate  treatment,  is  generally  established 
at  the  most  convenient  building  nearest  the  field  of  battle.  A 
red  flag  marks  its  place,  or  the  way  to  it,  to  the  conductors  of  the 
ambulance,  and  to  the  wounded  who  can  walk." 

71 8.. "The  active  ambulance  follows  the  troop  engaged  to 
succor  the  wounded  and  remove  them  to  the  depot.  For  this 
purpose,  the  conductor  should  always  have  the  necessary  assist- 
ants that  the  soldiers  may  have  no  excuse  for  leaving  the  ranks 
for  that  object." 

719.  .The  medical  director  of  the  division,  after  consultation 
with  the  Quartermaster-General,  distributes  the  medical  officers 
and  hospital  attendants,  at  his  disposal,  to  the  depots  and  active 
ambulances.     He  will  send  officers  and  attendants,  when  prao 


432  APPENDIX. 

ticable,  to  the  active  ambulances,  to  relieve  the  wounded  who 
require  treatment  before  being  removed  from  the  ground.  He 
will  see  that  the  depots  and  ambulances  are  provided  with  the 
necessary  apparatus,  medicines  and  stores.  He  will  take  post 
and  render  his  professional  services  at  the  principal  depot. 

720.  .If  the  enemy  endangers  the  depot,  the  Quartermaster 
takes  the  orders  of  the  General  to  remove  it,  or  to  strengthen  its 
guard. 

721 .  .The  wounded  in  the  depots,  and  the  sick,  are  removed, 
as  soon  as  possible,  to  the  hospitals  that  have  been  established 
by  the  Quartermaster-General  of  the  Army,  on  the  flanks  or 
rear  of  the  army. 

782.  .In  sieges,  the  field  officer  of  the  trenches  sees  that  men 
and  litters  are  always  ready  to  bring  off  the  wounded. 

929.  .No  officer  making  returns  of  property  shall  drop  from 
his  return  any  public  property  as  worn  out  or  unserviceable  un- 
til it  has  been  condemned,  after  proper  inspection,  and  ordered 
to  be  so  dropped. 

935..  .Every  officer  having  public  money  to  account  for,  and 
failing  to  render  his  account  thereof  quarter- yearly,  with  the 
vouchers  necessary  to  its  correct  and  prompt  settlement,  within 
three  months  after  the  expiration  of  the  quarter,  if  resident  in 
the  United  States,  and  within  six  months  if  resident  in  a  foreign 
country,  will  be  promptly  dismissed  by  the  President,  unless  he 
shall  explain  the  default  to  the  satisfaction  of  the  President. 
(Act  January  31,  1823.) 

936.  .Every  officer  entrusted  with  public  money  or  property 
shall  render  all  prescribed  returns  and  accounts  to  the  bureau 
of  the  department  in  which  he  is  serving,  where  all  such  returns 
and  accounts  shall  pass  through  a  rigid  administrative  scrutiny 
before  the  money  accounts  are  transmitted  to  the  proper  offices 
of  the  Treasury  Department  for  settlement. 

991..  .The  sick  will  be  transported  on  the  application  of  the 
medical  officers  to  the  Quartermaster. 

1005.  .Assistant  surgeons,  approved  by  an  examining  board 
and  commissioned,  receive  transportation  in  the  execution  of 
their  first  order  to  duty. 

101 3.. The  allowance  and  change  of  straw  for  the  sick  is 
regulated  by  the  surgeons. 


APPENDIX.  4oo 

1043.  .Officers  receiving  clothing  or  camp  and  garrison  equip- 
age, will  render  quarterly  returns  of  it  to  the  Quartermaster- 
General. 

1073.  .Issues  to  the  hospital  will  be  on  returns  by  the  medical 
officer,  for  such  provisions  only  as  are  actually  required  for  the 
sick  and  the  attendants.  The  cost  of  such  parts  of  the  ration  as 
are  issued  will  be  charged  to  the  hospital  at  contract  or  cost 
prices,  and  the  hospital  will  be  credited  by  the  whole  number  of 
complete  rations  due  through  the  month  at  contract  or  cost 
prices  (see  Note  7)  ;  the  balance,  constituting  the  Hospital  Fund, 
or  any  portion  of  it,  may  be  expended  by  the  commissary,  on 
the  requisition  of  the  medical  officer,  in  the  purchase  of  any 
article  for  the  subsistence  or  comfort  of  the  sick,  not  authorized 
to  be  otherwise  furnished  (see  Form  3).  At  large  depots  or 
general  hospitals,  this  fund  may  be  partly  expended  for  the 
benefit  of  dependent  posts  or  detachments,  on  requisitions  ap- 
proved by  the  medical  director  or  senior  surgeon  of  the 
district. 

1074.  .The  articles  purchased  for  the  hospital,  as  well  as  those 
issued  from  the  subsistence  storehouse,  will  be  included  in  the 
surgeon's  certificate  of  issues  to  the  hospital,  and  borne  on  the 
monthly  return  of  provisions  received  and  issued.  Vouchers 
for  purchases  for  the  hospital  must  either  be  certified  by  the  sur- 
geon or  accompanied  by  his  requisition. 

1075.  .Abstracts  of  the  issues  to  the  hospital  will  be  made  by 
the  commissary,  certified  by  the  surgeon  and  countersigned  by 
the  commanding  officer. 

1079.  .An  extra  issue  of  fifteen  pounds  of  tallow  or  ten  of 
sperm  candles,  per  month,  may  be  made  to  the  principal  guard 
of  each  camp  and  garrison,  on  the  order  of  the  commanding 
officer.  Extra  issues  of  soap,  candles,  and  vinegar,  are  permit- 
ted to  the  hospital  when  the  surgeon  does  not  avail  himself  of 
the  commutation  of  the  hospital  rations,  or  when  there  is  no 
hospital  fund ;  salt,  in  small  quantities,  may  be  issued  for  public 
horses  and  cattle.  When  the  officers  of  the  medical  depart- 
ment find  anti-scorbutics  necessary  for  the  health  of  the  troops, 
the  commanding  officer  may  order  issues  of  fresh  vegetables, 
pickled  onions,  suur-erout,  or  molasses,  with  an  extra  quantity  of 
37 


-Jo4  APPENDIX. 

rice  and  vinegar.  (Potatoes  are  usually  issued  at  the  rate  of 
one  pound  per  ration,  and  onions  at  the  rate  of  three  bushels  in 
lieu  of  one  of  beans.)  Occasional  issues  (extra)  of  molasses 
are  made— two  quarts  to  one  hundred  rations — and  of  dried  ap- 
ples of  from  one  to  one  and  a  half  bushels  to  one  hundred  ra- 
tions. Troops  at  sea  are  recommended  to  draw  rice  and  an  ex- 
tra issue  of  molasses  in  lieu  of  beans.  When  anti-scorbutics  arc 
issued,  the  medical  officer  will  certify  the  necessity,  and  the  cir- 
cumstances which  cause  it,  upon  the  abstract  of  extra  issues. 


EXTRACTS  FROM  GENERAL  ORDERS. 

I.  Ambulances  will  not  be  used  for  any  other  than  the  specific 
purpose  for  which  they  are  designed,  viz:  the  transportation  of 
the  sick  and  wounded ;  and  those  hereafter  provided  for  the 
army  will  be  made  according  to  a  pattern  to  be  furnished  the 
quartermaster's  department  by  the  Surgeon-General. 

II.  Paragraph  963  of  the  Regulations  for  the  Army  is  so  far 
amended  as  to  allow  the  medical  director  and  medical  purveyor 
of  a  military  department  one  room  each  as  an  office  ;  and  fuel 
therefor  from  the  1st  of  October  to  the  30th  of  April,  at  the  rate 
of  one  cord  of  wood  per  month. 


Officers  of  the.  medical  department  may,  by  virtue  of  their 
commissions,  command  all  enlisted  men,  like  other  commissioned 
officers.  Paragraph  13,  Army  Regulations,  will  not  be  inter- 
preted to  restrict  that  authority. 


1.  .Boards  of  Survey  will  nut    lie  resorted  to  for  the  condem- 
nation of  public  property,  but  only  to  establish  data  by  which 


APPENDIX.  435 

questions  of  administrative  responsibility  may  be  determined, 
and  the  adjustment  of  accounts  facilitated:  such  as  to  assess  the 
damage  which  public  property  has  sustained  from  any  extra- 
ordinary cause,  not  ordinary  wear,  either  in  transit  or  in  store, 
or  in  actual  use,  and  to  set  forth  the  circumstances  and.  fix  the 
responsibility  of  such  damage,  whether  on  the  carrier,  or  the 
person  accountable  for  the  property  or  having  it  immediately  in 
charge ;  to  report  from  examination  the  circumstances  and 
amount  of  the  loss  or  deficiency  of  public  property  by  accident, 
unusual  wastage,  or  otherwise,  and  fix  the  responsibility  of  such 
loss  or  deficiency  ;  to  make  inventories  of  property  ordered  to 
be  abandoned,  when  the  articles  have  not  been  enumerated  in 
the  orders ;  to  assess  the  prices  at  which  damaged  clothing  may 
be  issued  to  troops,  and  the  proportion  in  which  supplies  shall 
be  issued  in  consequence  of  damage  that  renders  them  at  the 
usual  rate  unequal  to  the  allowance  which  the  regulations  con- 
template; to  verify  the  discrepancy  between  the  invoices  and 
the  actual  quantity  or  description  of  property  transferred  from 
one  officer  to  another,  and  ascertain,  as  far  as  possible,  where 
and  how  the  discrepancy  has  occurred,  whether  in  the  hands  of 
the  carrier  or  the  officer  making  the  transfer  ;  and  to  make  in- 
ventories and  report  on  the  condition  of  public  property  in  the 
possession  of  officers  at  the  time  of  their  death.  The  action  of 
the  Board  for  the  authorized  object  will  be  complete  with  the 
approval  of  the  commanding  officer,  but  liable  to  revision  by 
higher  authority.  In  no  case,  however,  will  the  report  of  the 
Board  supersede  the  depositions  which  the  law  requires  with 
reference  to  deficiencies  and  damage. 

2 .  .  Boards  of  Survey  will  not  be  convened  by  any  other  than 
the  commanding  officer  present,  and  will  be  composed  of  as 
many  officers,  not  exceeding  three,  as  may  be  present  for  duty, 
the  commanding  officer  and  the  officer  responsible  in  the  matter 
to  be  reported  on  being  excluded;  but  in  ease  the  two  latter 
only  are  present,  then  the  one  not  responsible  will  perforin  the 
duties,  and  (he  responsible  officer  will  perform  them  if  no  other 
officer  is  present.  The  proceedings  of  the  Board  will  be  signed 
by  each  member,  and  a  copy  forwarded  by  the  approving  officer 
1u  the  head-quarters  of  the  department  or  army  in  the  field,  as 


436  •      APPENDIX. 

the   case  may   be,   duplicates  being    furnished    to   the   officer 
accountable  for  the  property. 

3.  .All  surveys  and  reports  having  in  view  the*  condemnation 
of  public  property,  for  whatever  cause,  will  be  made  by  the  com- 
manding officers  of  posts  or  other  separate  commands,  or  by 
inspectors-general,  or  inspectors  specially  designated  by  the 
commander  of  a  department  or  an  army  in  the  field,  or  by  higher 
authority.  Such  surveys  and  reports  having  a  different  object 
from  those  of  Boards  of  Survey,  will  be  required  independently 
of  any  action  of  a  Board  on  the  same  property. 

4.  .When  public  property  is  received  by  any  officer,  he  will 
make  a  careful  examination  to  ascertain  its  quality  and  condi- 
tion, but  without  breaking  packages  until  issues  are  to  be  made, 
unless  there  is  cause  to  suppose  the  contents  defective ;  and  in 
any  of  the  cases  supposed  in  the  first  paragraph,  he  will  apply 
for  a  Board  of  Survey  for  the  purposes  therein  set  forth.  If  he 
deem  the  property  unfit  for  use,  and  that  the  public  interest  re- 
quires it  to  be  condemned,  he  will,  in  addition,  report  the  fact 
for  that  purpose  to  the  commanding  officer,  avIio  will  make  a 
critical  inspection,  or  cause  it  to  be  made  by  an  inspector-gen- 
eral or  special  inspector,  according  to  the  nature  of  his  com- 
mand. .  If  the  inspector  deem  the  property  fit,  it  shall  be 
received  and  used.  If  not,  he  will  forward  a  formal  inspection 
report  to  the  commander  empowered  to  give  orders  in  the  case. 
The  same  rule  will  be  observed,  according  to  the  nature  of 
the  case,  with  reference  to  property  already  on  hand.  The  per- 
son accountable  for  the  property,  or  having  it  in  charge,  will 
submit  an  inventory,  which  will  accompany  or  be  embodied  in 
the  inspection  report,  stating  how  long  the  property  has  been  in 
his  possession,  how  long  in  use,  and  from  whom  it  was  received. 
The  inspector's  report  will  state  the  exact  condition  of  each 
article,  and  what  disposition  it  is  expedient  to  make  of  it :  as,  to 
be  destroyed,  to  be  dropped  as  being  of  no  value,  to  be  broken 
up,  to  be  repacked  or  repaired,  or  to  be  sold.  The  inspector 
will  certify  on  his  report  that  he  has  examined  each  article,  and 
that  its  condition  is  as  stated.  If  the  commanding  officer,  who 
ordinarily  would  be  the  inspector,  is  himself  accountable  for  the. 
property,  the  next  officer  in  rank  present  for  duty  will  act  as 


APPENDIX.  437 

the  inspector.  The  authority  of  inspection  and  condemnation 
will  not,  without  special  instructions,  extend  to  commanding 
officers  of  arsenals  with  reference  to  ordnance  and  ordnance 
stores,  but  may  in  regard  to  other  unserviceable  supplies. 

5 .  .  An  officer  commanding  a  department  or  an  army  in  the 
field,  may  give  orders,  on  the  report  of  the  authorized  inspectors, 
either  to  sell,  destroy,  or  make  such  other  disposition  of  con- 
demned property  as  the  case  may  require,  excepting  with  refer- 
ence to  the  sale  of  ordnance  and  ordnance  stores ;  but  if  the 
property  be  of  very  considerable  value,  and  there  is  reason  to 
suppose  that  it  could  be  advantageously  applied  or  disposed  of 
elsewhere  than  within  his  command,  he  will  refer  the  matter  to 
the  chief  of  the  staff  department  to  which  it  belongs.  No  other 
persons  than  those  designated,  or  the  General-in-Chief,  will  order 
the  final  disposition  of  condemned  property,  excepting  in  the 
case  of  ordnance  and  ordnance  stores,  which  are  to  be  dropped 
or  broken  up ;  horses  which  should  be  killed  to  prevent  conta- 
gion, and  provisions  or  other  stores  which  are  deteriorating  so 
rapidly  as  to  require  immediate  action.  In  this  last  case,  the 
inspector  may  order  the  destruction  or  sale  of  the  stores, 
and,  in  the  other  cases,  he  may  direct  the  dispositions 
above  indicated  with  reference  to  them.  The  inventories  will 
be  made  in  duplicate  :  one  to  be  retained  by  the  person  account- 
able, and  the  other  to  accompany  his  accounts.  When  the 
action  of  the  inspector  has  been  final,  a  copy  of  the  inventory 
will  be  forwarded  through  the  department,  or  other  superior 
head-quarters,  to  the  chief  of  the  staff  department  to  which  the 
property  belongs.  When  the  action  of  the  department  or  other 
superior  commander  is  required,  the  original  inventories  will  be 
sent  to  the  head-quarters,  and  returned  with  the  final  orders 
thereon  to  the  person  accountable  for  the  property,  and  a  copy 
of  the  inventory  and  orders  will  be  forwarded  from  the  depart- 
ment or  other  superior  head-quarters  to  the  chief  of  the  staff 
department  to  which  they  relate. 

G .  .  Ever}-  inspector,  member  of  a  Board  of  Survey,  and  com- 
mander acting  on  their  proceedings,  shall  be  answerable  that 
his  action  has  been  proper  and  judicious,  according  to  the  reg- 
ulations and  the  circumstances  of  the  case. 


43S  APPENDIX. 

7.  .As  far  as  practicable,  every  officer  in  charge  of  public 
property,  whether  it  be  in  use  or  in  store,  will  endeavor,  by 
timely  repairs,  to  keep  it  in  serviceable  condition,  for  which 
purpose  the  necessary  means  will  be  allowed  on  satisfactory 
requisitions ;  and  property  in  store  so  repaired  will  be  issued  for 
further  use.  Unserviceable  arms  will  be  sent  to  an  arsenal  for 
repair,  before  accumulating  in  excess  of  the  surplus  arms  in  the 
company.  Provisions  and  other  j)erishab]e  stores  will  be 
repacked  whenever  it  may  be  necessary  for  their  preservation, 
and  their  value  will  justify  the  expense,  which  will  be  a  legiti- 
mate charge  against  the  department  to  which  they  belong. 
Public  animals  will  not  be  condemned  for  temporary  disease  or 
want  of  condition,  but  may,  by  order  of  the  commanding  officer, 
after  inspection,  be  turned  in  for  rest  and  treatment,  if  unfit  for 
service  for  which  they  are  immediately  required. 

8.  .Public  property  shall  not  be  transferred  gratuitously  from 
one  staff  department  to  another ;  but  when  offered  for  sale,  and 
required  for  the  public  service  in  another  staff  department  in 
which  its  use  is  allowed  by  regulations,  it  may  be  bid  in  on  the 
order  of  the  commanding  officer,  or  purchased  at  a  fair  valuation, 
to  be  determined  by  a  Board  of  Survey,  if  there  should  be  no 
other  bidder. 

9.  .Paragraph  926,  Arm}-  Regulations,  and  so  much  of  any 
previous  orders  or  regulations  as  conflicts  with  the  foregoing, 
are  rescinded. 


It  is  desirable  to  furnish  ambulance  transportation  for  forty 
men  per  one  thousand  —  twenty  lying  extended  and  twenty 
sitting. 

Both  two  and  four  wheeled  ambulances  are  desirable  for  the 
hospital  service. 

A  two  wheeled  ambulance  is  the  best  for  the  conveyance  of 
dangerously  sick  or  dangerously  wounded  men. 

It  is  recommended  that  the  following  schedule  of  transports 
for  the  sick  and  wounded,  and  for  hospital  supplies,  be  adopt  ml 
for  a  state  of  war  with  a  civilized  enemy : 

For  commands  of  less  than  three  companies,  one  two  wheeled 


ATrKNDTX. 


439 


transport  cart  for  hospital  supplies,  and  to  each  company  one 
two  wheeled  ambulance. 

For  commands  of  more  than  three  and  less  than  five  com- 
panies, two  two  wheeled  transport  carts,  and  to  each  company 
one  two  wheeled  ambulance. 

For  a  battalion  of  five  companies,  one  four  wheeled  ambu- 
lance, five  two  wheeled  ambulances,  and  two  two  wheeled  trans- 
port carts.  For  each  additional  company  less  than  ten,  one  two 
wheeled  transport  cart. 

For  a  regiment,  two  four  wheeled  ambulances,  ten  two  wheeled 
ambulances,  and  four  two  wheeled  transport  carts. 

The  transport  carts  to  be  made  after  the  models  of  the  two 
wheeled  ambulances  (their  interior  arrangement  for  the  sick 
excepted),  and  to  have  solid  board  flooring  to  the  body. 

It  is  recommended  that  in  future  hospital  tents  be  made  ac- 
cording to  the  pattern  of  the  present  tent  and  of  the  same 
material,  but  smaller,  aud  having  on  one  end  a  lapel  so  as  to 
admit  of  two  or  more  tents  being  joined  and  thrown  into  one 
with  a  continuous  covering  or  roof. 

The  dimensions  to  be  these  :  In  length,  fourteen  feet;  in  width, 
fifteen  feet ;  in  height  (centre),  eleven  feet,  with  a  wall  four  and 
a  half  feet,  and  a  "fly"  of  appropriate  size.  The  ridge  pole  to 
be  made  in  two  sections  after  the  present  pattern,  and  to  meas- 
ure fourteen  feet  when  joined. 

It  is  contemplated  that  such  a  tent  will  accommodate  from 
eight  to  ten  patients  comfortably. 

The  following  allowance  of  tents  for  the  sick,  their  attendants, 
and  hospital  supplies  is  recommended : 


COMMANDS. 


For  one  company •  . . 

For  three  companies 
For  five  companies.  . 
For  seven  companies 
For  ten  companies  .  . 


Hospital 
tents. 


Sibley 
tents. 


Common 
tents. 


The  adoption  of  a  hospital  knapsack  is  recommended  to  be 


440  APPExmx. 

carried  by  a  hospital  orderly  upon  the  march  or  in  battle,  who 
is  habitually  to  follow  the  medical  officer.  The  knapsack  to  be 
made  of  light  wood ;  to  be  divided  into  four  compartments  or 
drawers,  and  to  be  covered  with  canvas.  The  purpose  of  this 
knapsack  is  to  carry,  in  an  accessible  shape,  such  instruments, 
dressings  and  medicines  as  may  be  needed  in  an  emergency  on 
the  march  or  in  the  field.  The  dimensions  of  the  hospital  knap- 
sack to  be  those  of  the  ordinary  knapsack. 


APPENDIX.  4+1 


COEEBSPONDBNCE. 

The  Surgeon-General  directs  that  official  letters,  addressed  to 
him  by  medical  officers  of  the  army,  be  written  on  letter  paper 
(quarto  post)  whenever  practicable,  and  not  on  note  or  foolscap 
paper.  Also,  that  the  letter  be  folded  in  three  equal  folds 
parallel  with  the  writing,  and  endorsed  on  that  fold  which  cor- 
responds with  the  top  of  the  sheet ;  thus  : 

(Name  and  rank  of  writer.) 

(Post  or  station  and  date  of  letter.) 

(Analysis  of  contents.) 


Appendix  jSTo.  2. 


MEMOBANDIJM 


INFORMATION  OF  MEDICAL  OFFICERS 

IN  THE  ENGLISH  ARMY, 

ON"    TAKING    THF3    FIELD    FOR    ACTIVE    SERVICE. 


1 .  . .  .  The  ambulance  equipment  for  one  division  of  the  army, 
consisting  of  two  brigades  of  three  battalions  each — the  battal- 
ions being  800  strong,  should  consist  of  two  large  store  wagons, 
to  be  under  the  care  of  a  purveyor's  clerk,  at  the  head-quarters 
of  the  division.  These  wagons  to  contain  a  reserve  supply  of 
medicines,  materials,  medical  comforts,  tents  and  bedding.  Each 
battalion  surgeon  should  have  a  pack-horse  for  the  conveyance 
of  his  instruments,  a  few  medical  comforts  for  immediate  use ; 
such  as  a  bottle  of  brandy,  half  pound  of  tea,  one  pound  of  su- 
gar, and  four  ounces  of  arrowroot,  a  few  tins  of  essence  of  beef, 
some  medicines,  and  a  supply  of  surgical  materials  agreeably  to 
the  printed  scale  laid  down  in  the  regulations.  A  spring  wagon 
should  also  be  attached  to  each  battalion  for  the  removal  of  the 
wounded  off  the  field,  and  for  the  conveyance  of  the  hospital 
canteens,  A  and  B,  with  twelve  sets  of  bedding,  ten  canvas 
bearers,  and  the  hospital  marquee  on  the  line  of  march  :  or, 
when  the  spring  wagons   are  either  small,  or  required  for  the 


444  APPENDIX. 

conveyance  of  sick   and   wounded,  a  reserve  wagon  might  be 
attached  to  each  brigade  for  the  carriage  of  these  articles. 

Canvas  bearers  with  long  poles,  and  shoulder  straps,  in  pro- 
portion of  two  to  every  hundred  men,  will  also  be  required. 

2.  . .  .Before  a  division  takes  the  field,  the  principal  medical 
officer  should  satisfy  himself  by  personal  inspection,  that  the 
equipment  of  surgeons  of  regiments  is  complete  in  every  respect, 
and  it  would  be  a  necessary  precaution  for  him  to  see  the  pack 
horses  loaded  in  his  presence,  as  by  that  means  he  would  ascer- 
tain that  no  straps,  buckles,  or  cords  were  wanting. 

3.  . .  .When  an  action  with  the  enemy  seems  inevitable,  the 
surgeon  of  each  regiment  will  make  arrangements  for  the  re- 
moval of  the  wounded  of  his  corps  from  the  field,  and  it  would 
be  desirable  for  him  to  give  some  instructions  to  the  bandsmen, 
and  others  employed  in  that  duty,  how  to  apply  a  field  tourni- 
quet, to  restrain  dangerous  hemorrhage  until  the  assistance  of  the 
medical  officer  on  the  field  can  be  obtained ;  and  for  this  purpose 
a  tourniquet  should  be  given  to  each  party  of  bearers.  The 
bearers  should  also  each  of  them  carry  a  canteen  full  of  water. 

4 .  .  .  .  While  the  troops  are  advancing,  the  medical  officers  will 
follow  with  the  spring  wagons  and  bearers,  and  any  other  con- 
veyance that  is  available ;  but  when  they  deploy,  or  form  for 
action,  all,  except  one  medical  officer  per  regiment,  will  move  a 
short  distance  to  the  rear,  out  of  musket  range,  and  will  prepare 
for  affording  aid  to  the  wounded,  and  performing  such  primary 
operations  as  may  be  deemed  absolutely  necessary.  For  this 
purpose  the  surgical  panniers  must  be  brought  up,  and  instru- 
ments, ligatures,  dressings,  and  cordials  (brandy)  got  ready,  and, 
above  all  things,  an  abundant  supply  of  water  provided,  for  the 
safe  and  easy  conveyance  of  which,  the  leather  bags,  or  skins, 
formerly  recommended,  would  be  found  most  convenient. 

Dr.  Hall  takes  this  opportunity  of  cautioning  medical  officers 
against  the  use  of  chloroform,  in  the  severe  shock  of  serious  gun- 
shot wounds,  as  he  thinks  few  will  survive  where  it  is  used.  But, 
as  public  opinion,  founded,  perhaps,  on  mistaken  philanthropy, 
he  knows,  is  against  him,  he  can  only  caution  medical  officers, 
and  entreat  they  will  narrowly  watch  its  effects,  for  however 
barbarous  it  may  appear,  the  smart  of  the  knife  is  a  powerful 


APPENDIX.  445 

stimulant,  and  it  is  much  better  to  hear  a  man  bawl  lustily  than 
to  see  him  sink  silently  into  the  grave. 

5 .  . .  .  One  medical  officer  for  each  regiment,  generally  the 
junior  assistant  surgeon,  should  follow  the  troops  within  musket 
range,  so  as  to  be  at  hand  to  check  any  alarming  hemorrhage, 
and  to  expedite  the  removal  of  the  wounded  off  the  field  to  the 
rear,  and  for  this  purpose  the  bearers  should  be  placed  under 
his  orders,  and  the  regimental  spring  wagon  be  so  stationed  as 
to  be  within  easy  reach,  to  convey  them  to  where  the  surgeon 
and  his  assistants  have  established  themselves.  The  field-assist- 
ant should  carry  with  him,  in  his  haversack,  his  pocket  case  of 
instruments,  with  a  few  ligatures  ready  cut,  two  field  tourni- 
quets, some  but,  and  two  or  three  bandages ;  and  he  should  be 
accompanied  by  three  men,  one  with  a  knapsack,  or  haversack, 
containing  one  pint  bottle  of  brandy,  or  some  other  stimulant, 
twenty-four  bandages,  half  a  pound  of  lint,  three  sponges,  six 
long  and  six  short  solid  splints,  two  old  sheets  cut  into  quarters 
before  starting,  for  the  purpose  of  rolling  fractured  limbs  in,  and 
so  preventing  them  from  sustaining  further  injury  on  the  men's 
removal  from  the  field.  This  is  best  accomplished  by  placing 
the  old  linen  under  the  limb,  and  rolling  the  splint  up  in  it  from 
the  outer  edge,  and  rolling  toward  the  limb  on  each  side,  and 
then  securing  the  whole  with  two  or  three  bands  of  tape.  In 
this  way  Dr.  Hall  thinks  medical  officers  will  find  they  can  tem- 
porarily secure  fractured  limbs  better  and  much  more  expe- 
ditiously than  in  any  other  manner.  The  orderly  should  have 
in  his  haversack,  in  addition  to  the  above  articles,  a  piece  of 
tape,  some  pins,  and  two  or  three  rolls  of  tow.  He  should  carry 
a  canteen,  either  of  wood  or  india-rubber,  full  of  water,  and  a 
drinking  cup.  The  second  man  should  carry  a  canvas  bearer, 
with  shoulder  straps,  and,  like  the  former,  should  have  a  canteen 
full  of  water.  The  third  man,  I  think,  should  be  armed,  to  pro- 
tect the  party  against  stragglers  and  marauders,  and,  like  his 
fellows,  carry  a  canteen  fall  of  water.  The  second  assistant  sur- 
geon should  receive  the  wounded  from  the  field,  see  them  care- 
fully placed  in  the  spring  wagon,  and  then  accompany  the  spring 
wagon  to  where  (lie  surgeon  and  third  assistant  arc  stationed, 
ready  to  afford  them  the  surgical  aid   they  may  require.     For 


440  APPENDIX. 

this  service  the  second  assistant  surgeon  should  be  accompanied 
by  two  men  to  assist  in  placing  the  men  carefully  in  the  wagon ; 
these  men  should  accompany  the  wagon,  and  assist  in  like  man- 
ner in  taking  the  wounded  out.  These  men  should  likewise 
carry  canteens  full  of  water,  and  there  should  be  a  skin  of  water 
as  a  reserve,  in  the  wagon,  with  a  drinking  cup. 

6 .  . .  .  The  site  selected  by  the  staff-surgeon  of  brigade  for  the 
reception  of  the  wounded  from  the  field  should  be  as  sheltered 
as  possible ;  and  if  not  easih'  distinguished,  a  flag  should  be  put 
up;  and  if  any  houses  be  near,  calculated  for  the  reception  of 
wounded  men,  they  should  be  taken  possession  of  at  once,  and  an 
abundant  supply  of  water,  and,  if  possible,  straw  provided. 

7 .  . .  .  Should  the  action  prove  decisive,  tents  can  be  pitched 
for  the  temporary  accommodation  of  the  wounded;  but  should 
the  army  advance,  the  surgeon,  and  one  assistant,  at  least,  should 
accompany  their  regiments,  leaving  one  or  two  assistants,  accord- 
ing to  the  number  of  wounded,  to  aid  the  divisional  staff,  who 
will  pitch  the  reserve  marquees,  and  make  all  necessary  prepar- 
ation for  the  comfort  and  accommodation  of  the  wounded  by 
having  tea,  broth,  or  essence  of  beef  (which  is  readily  made  into 
broth  by  adding  hot  water),  wine,  and  brandy,  etc.,  ready. 
Should  the  army  unfortunately  meet  with  a  reverse,  all  avail- 
able transport  must  be  pressed  for  the  removal  of  the  wounded 
to  the  rear,  and  they  must  be  sent  off  as  speedily  as  possible ; 
but  neither  here,  nor  on  the  field  of  battle,  should  any  one  be 
carried  whose  hurts  are  so  slight  as  to  admit  of  his  walking. 
Nor  should  commanding-officers  of  regiments,  when  wounded,  be 
allowed  to  take  medical  officers  of  their  own  corps  to  the  rear 
with  them,  or  officers  of  any  grade  be  permitted  to  appropriate 
the  spring  wagons  for  the  special  conveyance  of  themselves  and 
their  luggage  ;  and  positive  orders  should  be  given  to  prevent 
bandsmen,  drummers,  or  pioneers,  specially  told  off  to  assist  the 
wounded,  from  being  left  in  charge  of  officers'  horses  and  effects. 

8.  .  .  .Should  the  army  have  to  effect  a  landing  on  an  enemy's 
coast,  with  an  opposing  force  to  meet  it,  the  men  should  eat  a 
good  meal  before  leaving  the  ships,  and  should  cook  whatever 
provisions  it  is  necessary  to  serve  out  to  them  before  the  start. 
Pork  is  better  than  beef  for  this  purpose,  as  it  warms  up  more 


ArPENPIX. 


447 


readily  with  any  vegetable  the  men  may  find  on  shore.  The 
medical  officers  should  land  with  the  last  boats  of  their  regi- 
ments, and  should  carry  with  them  their  haversacks,  dressings, 
and  canvas  bearers,  if  the  landing  be  opposed,  so  as  to  be  able 
to  bring  the  wounded  at  once  to  the  boats  for  conveyance  to  the 
ships  set  apart  for  their  reception;  care  should  be  taken  that 
each  boat  employed  in  this  service  contains  a  supply  of  water 
and  a  drinking  horn. 

9 .  .  .  .  Should  a  landing  be  effected,  and  any  horses  be  disem- 
barked, the  surgeon's  pack-horse  and  panniers  should  be  amongst 
the  first. 

10.  . .  .  As  soon  after  an  action  as  possible,  medical  officers  in 
charge  of  corps  will  make  out  and  transmit  to  the  Inspector- 
General  of  hospitals,  for  the  information  of  the  General  com- 
manding-in-chief, returns  of  casualties  made  out  agreeably  to 
the  following  form : 

Return  of  Killed  and  Wounded  in   the Regiment,  in   the   Action 

of  -— . 


Killed. 

Wounded. 

Total 

Wounded. 

Danger- 
ously. 

Severely 

Slightly 

1!  KM  ARKS. 

Officers. 

Non-com- 
missioned 
officers 
and  pri- 
vates. 

Names  of  officers  kill- 
ed  and  wounded  to 
be  inserted  here. 

RARE  BOOK 
COLLECTION 


THE  UNIVERSITY  OF 

NORTH  CAROLINA 

LIBRARY 


3C27 
Conf. 


